UNITED STATES PUBLIC HEALTH SERVICE 

RUPERT BLUE, Surgeon General 



VITAL STATISTICS 

A DISCUSSION OF WHAT THEY ARE AND THEIR 
USES IN PUBUC HEALTH ADMINISTRATION 



BY 



JOHN W. TRASK 

Assistant Surgeon General 
United States Public Health Service 



SUPPLEMENT No. 12 

TO THE 

PUBLIC HEALTH REPORTS 

ApeIL 3, 1914 
[SECOND EDITION] 




WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1914 



UNITED STATES PUBLIC HEALTH SERVICE 

RUPERT BLUE, Surgeon General 



A DISCUSSION OF WHAT THEY ARE AND THEIR 
USES IN PUBLIC HEALTH ADMINISTRATION 



BY 



JOHN W. TRASK 

Assistant Surgeon General 
United States Public Health Service 



SUPPLEMENT No. 12 

TO THE 

PUBLIC HEALTH REPORTS 

April 3, 1914 
[SECOND EDITION] 




WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1914 



U-iMl^ 



\A^.; 






HEALTH OFFICEES AND OTHER PERSONS 

ENGAGED IN PUBLIC HEALTH -Wore, jPHTSICIANS 

AND MEDICAL STUDENTS CAN OBTAIN COPIES 

OF THIS PUBLICATION BY ADDRESSING THE 

SURGEON GENERAL, UNITED STATES 

PUBLIC HEALTH SERVICE 

"WASHINGTON, D.C. 

V 



D. OF 0. 
OCT 20 1914 






CONTENTS, 



Introduction. 7 

Vital statistics 8 

Definition 8 

Development 8 

Based on population 9 

Population statistics 9 

Source of data 9 

Nature of census information 10 

Sources of error in census enumerations 10 

Fluctuation in population 11 

Estimates of population 12 

Arithmetical method 12 

Geometrical method 13 

Marriage statistics 14 

Marriage rates 15 

Factors influencing marriage rates 15 

Uses of marriage registration 17 

Birth statistics 17 

Registration in England 17 

Registration in the United States 18 

Colonial period 18 

Post-colonial period 19 

Recent development 20 

Source of data 21 

Nature of information secured by registration 21 

Standard birth certificate for the United States 22 

Birth rates 1 22 

Rate per 1,000 population 22 

Rate per 1,000 women of child-bearing age 23 

Rate of legitimate births per 1,000 married women of child-bearing 
age (15 to 44, or 15 to 49 years of age), and of illegitimate births per 

1,000 unmarried wom.en 24 

Sources of error in birth statistics 24 

Uses of birth registration and statistics 25 

Legal record 25 

Uses in public health administration 25 

Factors influencing birth rates 26 

Morbidity statistics 27 

Morbidity statistics in England and Wales 28 

Morbidity statistics in Russia 29 

Morbidity statistics in the United States 29 

Advocated by American Medical Association and others 29 

First developed in Massachusetts 30 

Early development in Michigan 34 

Present status. 35 

(3) 



Morbidity statistics — Continued. Page. 

The notifiable diseases 37 

The model State law for morbidity reports 37 

The, results of notification in certain States and cities 39 

Diphtheria 40 

Measles. 40 

Typhoid fever - 41 

Source of statistical data 42 

Nature of information secured by morbidity notification 45 

The standard notification blank 45 

Sources of error in morbidity statistics 46 

Uses of morbidity reports and statistics 47 

Morbidity rates 48 

Crude morbidity rates 48 

Specific morbidity rates 48 

Fatality rates 49 

Hospital statistics and sickness insurance records 49 

Factors influencing morbidity rates 49 

Notification of occupational diseases 50 

Mortality statistics 51 

Registration of deaths in England and the United States 52 

United States registration area for deaths 52 

Source of data 53 

The standard death certificate 54 

Sources of error 54 

Uses of death registration 59 

Death rates - 59 

Crude death rates 59 

Death rates for short periods 60 

Specific death rates 60 

Standardized death rates 61 

Factors affecting death rates 62 

Nonresidents — hospitals and institutions 63 

Migration 63 

Birth rate - 64 

Marital condition 64 

Infantile mortality 68 

Life tables 68 

Acknowledgments 69 

TABLES. 

Table 1. — Showing growth of population in certain countries in millions, 1800 

to 1910 11 

Table 2. — Number of persons married per 1,000 population in certain countries, 

1892 and 1911 16 

Table 3. — Birth rates (exclusive of stillbirths) per 1,000 population in certain 

countries, 1886 and 1911 26 

Table 4. — Diphtheria — Cases notified, case rates per 1,000 population, number 
of cases notified for each fatality (death) registered, and fatality rates per 100 
cases, in States and cities haviag 10 or more cases notified for each death 

registered, 1912 40 

Table 5. — Measles — Cases notified, case rates per 1,000 population, number of 
cases notified for each fatality (death) registered, and fatality rates per 100 
cases, in States and cities having 50 or more cases notified for each death 

registered, 1912 - 40 



Page. 

Table 6. — Typhoid fever — Cases notified, case rates per 1,000 population, 
number of cases notified for each fatality (death) registered, and fatality rates 
per 100 cases, in States and cities having 7 or more cases notified for each 
death registered, 1912 41 

Table 7. — Showing for the period 1886-1895, the number of deaths per 10,000 

persons according to their marital status in France, Prussia, and Sweden 64 

Table 8. — Death rates (exclusive of stillbirths) per 1,000 population in certain 
countries, 1886 and 1911 64 

Table 9. — Comparison of mortality of males and females, by age groups; death 
rates per 1,000 population 65 

Table 10. — Death rates per 1,000 persons at different age periods in New 
York City, with increase or decrease percentage from all causes for the years 
1868 and 1907 65 

Table 11. — Infantile mortality — Deaths of children under 1 year of age per 

1,000 birtlis (exclusive of stillbirths) in certain countries, 1892 and 1911 68 

Table 12. — ^Approximate life tables for the city of New York based on mor- 
tality returns for the triennials 1879 to 1881 and 1909 to 1911 69 

CHARTS. 

Chart 1. — -Population of the United States in millions, 1810 to 1910; and of 
Massachusetts in hundred thousands, 1765 to 1910 13 

Chart 2. — Number of persons married per 1,000 population per annum — Eng- 
land and Wales— 1840 to 1910 15 

Chart 3. — Births (including stillbirths), persons married, and deaths (exclud- 
ing stillbirths) registered per 1,000 population per annum — Michigan — 1871 
to 1911 16 

Chart 4. — Bhths and deaths (exclusive of stillbirths) per 1,000 population per 
annum — England and Wales — 1840 to 1910 23 

Chart 5. — Births and deaths (exclusive of stillbirths) per 1,000 population per 
annum — Massachusetts — 1850 to 1910 24 

Chart 6. — Smallpox — Number of cases notified per annum in Michigan from 

1883 to 1912 33 

Chart 7. — Smallpox — Number of cases notified per annum for each death reg- 
istered— Michigan— 1883 to 1912 34 

Chart 8. — Scarlet fever — Number of cases notified per annum for each death 
registered— Michigan— 1884 to 1910 35 

Chart 9. — Measles — Number of cases notified per annum for each death regis- 
tered— Michigan— 1890 to 1910 36 

Chart 10. — Diphtheria — Number of cases notified per annum for each death 

registered— Michigan— 1884 to 1910 42 

Chart 11. — Diphtheria — Fatality rate (number of deaths registered per annum 
per 100 notified cases) — Michigan — 1884 to 1910 43 

Chart 12. — Births and deaths (exclusive of stillbirths) per 1,000 population per 
annum — German Empire — 1886 to 1911 60 

Chart 13. — Births and deaths (exclusive of stillbirths) per 1,000 population per 

annum— France— 1886 to 1911 62 

Chart 14. — Births and deaths (exclusive of stillbirths) per 1,000 population per 

annum — Massachusetts — 1871 to 1911 63 

• Chart 15. — Infantile mortality (deaths of infants under one year of age per 1,000 
births per annum, exclusive of stillbirths) — German Empire, France, England 
and Wales, Denmark, Sweden, and New Zealand— 1892 to 1911 67 

Chart 16. — Infantile mortality (deaths of infants under 1 year of age per 1,000 

births per annum, exclusive of stillbirths) — England and Wales — 1840 to 1910. 67 



6 

APPENDIX. 

Early registration in England — Order of Thomas Cromwell, Vicar General Page, 
under Henry VIII (1538), requiring the clergy to record baptisms, marriages, 

and burials 71 

The model State law for morbidity reports 71 

The standard morbidity notification blank 74 

Hospital discharge certificate 75 

Notification of occupational diseases, United States — Abstracts of State laws 

and regulations 76 

California 76 

Connecticut 76 

Illinois 76 

Kansas 76 

Maine 77 

Maryland 77 

Massachusetts 77 

Michigan 77 

Minnesota 78 

Missouri 78 

New Hampshire 78 

New Jersey 79 

New York 79 

Ohio 79 

Pennsylvania 79 

Wisconsin 80 

Occupational diseases required by State laws to be reported (table) 80 

Occupational diseases — Information to be given in reports by physicians 

(table) ' 81 

Occupational diseases — Other provisions of the several State laws (table)... 82 

The model State law for the registration of births and deaths 83 

The standard birth and death certificates 92 

United States standard certificate of birth 93 

Supplemental report of birth 93 

United States standard certificate of death 94 



VITAL STATISTICS. 



A DISCUSSION OF WHAT THEY ARE AND THEIR USES IN PUBLIC 
HEALTH ADMINISTRATION. 

By John W. Trask, Assistant Surgeon General, United States Public Health Service. 



Vital statistics are the statistics of life. 

Morbidity statistics are the statistics of disease. 

Mortality statistics are the statistics of deaths. 

Birth, death, and migration statistics relate to population movement. 

Statistics of births and of immigration show population increment. 

Statistics of deaths and of emigration show population decrement. 



Statistics have suffered in reputation because of the seeming truth 
of the trite statement that one can prove anything by figures. In 
reahty figures are but evidence upon which conclusions may be based. 
If the evidence is faulty and the faults are not perceived, errors in 
judgment may result. But this is true of all evidence upon which 
opinions are based and is no more true of figures and statistics than 
it is of other kinds of evidence. 

Statistics are derived from the collection and numerical classifica- 
tion of observations relating to certain facts or events. They are 
usually limited to the systematic collection and classification of data 
relating to relatively large classes of events. In the maldng of sta- 
tistics the first and essential step is the recording of observations. 
After the observations have been noted a numerical compilation of 
their frequency or of the frequency of certain of their conditions or 
attributes is possible. The derived statistics being but a numerical 
classification or analysis of the recorded events depend primarily for 
their usefulness upon the accuracy of the original records of facts. 
They depend secondarily upon the accuracy of statistical classifica- 
tion and compilation. 

The original notation of facts and of the occurrence of events is 
usually secured in one of two ways, by enumeration or by registration. 
Observations relating to the population are made for example by 
enumeration at the decennial censuses. The census enumerators 
go from house to house and secure certain information regarding each 
individual. The enumerators are the observers who secure the 
original data. Statistics of population are made by the classification 
of the information thus obtained and the numerical compilation of 
the frequency of certain attributes. 

On the other hand, the notation of facts relating to deaths is 
secured by registration. For each individual who dies there is regis- 

(7) 



8 

tered wifcli an oflicial Imowii as a registrar certain information regard- 
ing the deceased and the cause and time of death. Here the observers 
who record the original data are the physicians, members of f amihes, 
and undertakers. From the classification and compilation of the 
information thus recorded mortahty statistics are made. Statistics 
of population depend for their accuracy upon the correctness of the 
records made by the enumerators and mortality statistics upon the 
accuracy of the information registered in death certificates. 

The statistical method is in itself dependable, although it is true 
that statistics may be vitiated by the use of inaccurate or incomplete 
data as a basis or of faulty methods in classification and compilation. 
Conclusions drawn from statistics by those who attempt to use them 
may be quite erroneous, but this is more often due to the limitations 
of the user than to the limitations of the statistics. The most com- 
mon error in the use of statistics is perhaps the comparing of numerical 
statements or ratios which are too dissimilar to allow of comparison. 

To make dependable statistics the original observations and 
records from which they are derived must be true and accurate, and 
the classification, compilation, and analysis must be done by com- 
petent individuals. The value of statistics when thus handled is 
shown by the use made of life tables by actuaries of life insurance 
societies and companies. 

Vital Statistics. 

Definition. — Vital statistics may be defined as statistics relating 
to the life histories of communities or nations. They pertain to 
those events which have to do with the origin, continuation, and 
termination of the lives of the inhabitants. They commonly include 
statistics of births, marriages, and deaths, and the conditions attend- 
ing these events. With these are usually also classed statistics of 
the occurrence of disease — morbidity statistics. Morbidity statistics, 
however, differ markedly from the others in their manner of collection 
and uses, so that to a greater degree than any of the others they 
constitute a class by themselves. 

Guilfoy has given a descriptive definition which in slightly abbre- 
viated form is that vital statistics are "the numerical registration 
and tabulation of population, marriages, births, diseases, and deatlis, 
coupled with analyses of the resulting numerical phenomena." ^ 

Development. — Vital statistics are not a thing of recent origin. 
Their development to their present form, however, is comparatively 
modern. The Egyptians, Greeks, and Romans made census enumer- 
ations. Some of the ancients, notably the Romans, required also 
the registration of births and deaths. The statistical treatment of 
the records was, however, comparatively limited. During the last 

1 Guilfoy, W. 11., Vital statistics in the promotion of public health, Nevv^ York Medical Journal, Nov. 5^ 
1910. 



9 

century and a half, and more particularly tlie last 50 years, the treat- 
ment of vital statistics has been undergoing a rapid evolution. In 
their present developed form they give a fund cf useful informa- 
tion otherwise unobtainable. They have become an essential to every 
well-organized community and nation. They give a composite 
picture of the life history cf a people which can be secured in no 
other way. They furnish a m.eans of comparing the life history of 
one community cr people with that of others and of the present 
with the past. 

Based upon population. — All vital statistics are baaed upon the 
population. The frequency of births, marriages, sickness, and deaths is 
expressed in terms of the population, usually as rates giving the 
number for each 1,000 inhabitants or class of inhabitants. In com- 
paring different communities or different periods, births, marriages, 
deaths, and the incidence of disease must be based upon a common 
unit of population. The first requisite to useful vital statistics is 
statistics of population showing the number of inhabitants, classified 
according to age, sex, nativity, race, and occupation. It would be 
desirable, if possible, to have also a classification according to econo- 
mic status, as birth, siclaiess, marriage, and mortality rates fre- 
quently vary with the incomes of individuals or households. An 
understanding of population statistics is therefore the primary 
essential to the comprehension or use of vital statistics, and statistics 
of population •will be first considered. 

POPULATION STATISTICS. 
Source of Data. 

The principal source of information regarding population under 
existing conditions is a census enumeration. For the United States 
these enumerations are made every 10 years. The last census was 
taken as of April 15, 1910. In the United States a census has been 
taken every 10 years since 1790, in Great Britain every 10 years 
since 1801. In taking a census it is desirable in so far as possible 
to take it at a time when the greatest number of people will be at 
their usual homes. A midwinter census would find many people 
absent from the Northern States and an unusual number in southern 
winter resorts. A midsummer census would find an unusual number 
at the seashore and at other summer resorts. A number of the 
States take a census midway between the United States decennial 
censuses, so that they have an enumeration of the population every 
five years. 

As the only source of definite iziformation as to population is the 
census enumeration, and as the population is continually changing, 
in most cases increasing, it is necessary to make estimates of the 
population for the periods between the census enumerations upon 



10 

wliicli to base rates for the various vital events and especially for 
the accurate computation and expression of marriage, birth, death, 

and sickness rates. 

Nature of Census Information. 

The taking of a census consists usually of more than a mere enumer- 
ation of ail persons living at the time the census is taken. It includes 
the recording of certain information regarding each individual. In 
taking the 1910 United States census the following information relat- 
ing to each individual was recorded by States, counties, and town- 
ships, viUages or cities: Name; address; sex; color or race; age at 
last bu'thday; whether single, married, widowed, or divorced; number 
of years of present marriage; mother of how many children, total 
number born, number now hving; individual's place of birth, place 
of birth of his father and mother; year of migration to the United 
States; whether naturalized or alien; whether able to speak English, 
and if not, the language spoken; the individual's occupation, the 
kind of work done and the industry or business in which employed; 
whether an employer, employee, or working on own account ; whether 
employed or out of work April 15; whether able to read and 'write; 
whether attending school; whether he owns the home in which he 
lives ; whether a survivor of the Union or Confederate ili'my or Navy ; 
whether blind in both eyes, or deaf and dumb. 

From the information thus obtained the statistics of population 
are made. By the classification and numerical compilation of this 
data it is possible to ascertain the composition and distribution of 
the population as to sex, color or race, age, marita,! status, fecundity, 
nativity, occupation, literacy, blindness, and deaf-mutism. 

Sources of Error in Census Enumerations. 

A certain number of individuals wih be enumerated both at the 
place Vv^here they happen to be and at then* proper residences. A few 
wiU be missed entirely. However, the degree of error thus caused 
will not be great. 

The margin of error in the securing of ages is greater. The age 
recorded is customarily intended to be the age in years at the last 
birthday. The ages given for children under 5 years old are likely 
not to be accurate due to the tendency to give the age of a child 
between 6 and 12 months of age as 1 year old and that of a chUd 
between 1 and 2 years old as 2 years of age. This tendency to give 
the age at the next birthday persists up to about the fifth year, 
although it is perhaps greatest during the first and second year. To 
avoid the error thus arising, the United States census records the ages 
of children under two yeai-s of age in years and months. For 
example, a child 6 months of age is recorded as six-tweKths of a year 
old and a child of 17 months of age as 1^ years old. 



11 



Women 15 to 20 years of age are prone to give their ages as betv/een 
20 and 25 years. Adults over 25 years of age frequently do not know 
their exact ages and are prone to approximate their ages as being 30 
or 40 or 50 years, and to a less extent at 35 or 45 or 55 years. The 
result is that there is at each census an exaggerated number of ages 
of 30, 40, 50 years, and also a lesser exaggeration of ages 35, 45, 55, 
and 65 years. Individuals over 80 years of age are prone to give 
their ages as greater than they really are. 

There is also a considerable margin of error in the recording of 
occupation. This is due largely to an imperfect understanding of 
what is wanted and to the multiplicity of occupations and a lack of 
knowledge as to their proper designation. 

Fluctuation in Population. 

Populations are constantly changing. Individuals are continually 
being added by immigration. In the United States, and more par- 
ticularly in some sections of the United States, considerable numbers 
are annually being added in this way. Immigration is also an impor- 
tant factor in the growth of population in certain South American 
countries. South Africa, New Zealand, Austraha, and Canada. 

Populations suffer a continuous diminution by reason of emigi-a- 
tion. This is especially true of some European countries. 

Migrations not only may affect the population of a country as a 
whole but also may alter the distribution of people within a country. 
There is in many countries a constant movement of people from rural 
localities to the cities and from one locality to another. 

All populations are also being increased by births and suffering 
losses by deaths. The rate of change, however, resulting from births 
and deaths is usually comparatively constant or alters gradually, 
while the changes due to migrations may be exceedingly irregular. 
Tlie increase in the population caused by the excess of bbths over 
deaths is kno'WTi as the natural increase. A country in which the 
birth and death rates are equal and in which the factor of migration 
is neghgible wUl have a fixed population. 

The increase of population in certain countries is shown by the fol- 
io v/ing table: 

Table 1. — Showing groivth of population of certain countries in millions, 1800 to 1910. 





1800 


1830 


1860 


1890 


1910 


France 


27 
16 
35 
25 
17 
10 


32 
24 
45 
29 
21 
11 
3 
2 
12 


36 
29 
68 
34 
25 
15 
4 
3 
31 


38 
38 
92 
40 
30 
17 
6 
4 
62 


39 


Great Britain and Ireland .. . 


44 


Russia in Europe 

Austria 


49 


Italy 


34 


Spain 


19 


Belgium . .. 


7 


Sweden 


2 
5 


5 


United States 


92 







12 

Estimates of Population. 

The frequency of births, marriages, or deaths is usually expressed as 
the number occurring during the calendar year per 1,000 population. 
The figures thus given are known as the birth, marriage, or death rates 
and are computed upon the mean population — that is, the number of 
inhabitants estimated to have existed at the middle of the year, 
July 1. These estimates are necessary for all dates except those on 
which census enumerations are made. For the making of estimates 
there are two methods commonly used, known, respectively, as the 
arithmetical and the geometrical methods. In each method the 
populations at the last two census enumerations form the known 
quantities from which the estimates are derived. 

AritJimetical metJiod.- — In the arithmetical method it is assumed 
that the increase or decrease in population which occurred between 
the last two census enumerations took place in equal amounts during" 
each intercensal year and will continue to take place annually in like 
numbers until the next census shall have been taken. Thus, given a 
city which had a population of 50,000 at the 1900 census (June 1, 
1900) and one of 61,850 at the 1910 census (Apr. 15, 1910), the increase 
during the intercensal period (9 years and lOJ months) would be 
11,850 and the annual increase according to the arithmetical method 
would be 

61,850-50,000 

ml , or 1,200 

If it is desired to estimate the population as of July 1, 1906, for the 
purpose of calculating annual rates, this is done by adding to the 
population as it existed June 1, 1900, the sum of 1,200 for each year 
intervening between the date of enumeration (June 1, 1900) and the 
date for which the estimate is to be made (July 1, 1906). There 
being 6 years and 1 month between these dates, the calculation 
would be 

50,000 + (e^L X 1,200) = 57,300. 

This same annual increase is also assumed to occur until the next 
census shall have been taken, so that if it is desired to estimate the 
population for July 1, 1914, take the population at the preceding 
census (Apr. 15, 1910) and add 1,200 for each year intervening be- 
tween its enumeration and the date for which an estimate is desired 
(July 1, 1914). There being 4 years and 2 J months between these 
dates, the calculation would be 

61,850 + (4^ X 1,200) = 66,900. 

This method assumes the same amount of increase each year and 
is analogous to the calculation of simple interest. It does not take 
into account the fact that with the annual increase in population the 



13 

number of persons of marriageable age and therefore the number of 
married persons will be greater each year and consequently the 
number of births. The growth due to natural increase (the excess of 
births over deaths) is analogous to the increment of compound 
interest, and where this factor (the natural increase) is the principal 
one affecting the population growth estimates of population made by 
the arithmetical method are unsatisfactory, and especially so where 
the estimate is made for a date several years away from a census 
enumeration. Where the excess of births over deaths is the con- 
trolling factor in population growth the geometrical method of mak- 



1770 1780 1790 1800 I8I0 1820 1830 1840 1850 I860 1870 1880 1890 1900 1910, 

































































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Chart L— Population of the United States, in millions, 1810 to 1910; and of Massachusetts, in hundred 

thousands, 1765 to 1910. 

ing estimates, being based on the principle of compound interest, is 
more accurate. Where the chief factor in population change is 
migration, or where the relative importance of natural mcrease is 
much affected by migration, the arithmetical method may be the 
more accurate. The arithmetical method has been the one found 
most reliable in the United States and is the method used by the 
Bureau of the Census. The method best adapted to a given popu- 
lation can be ascertained by taking the last two intercensal periods 
and finding whether the rate of increase during the last intercensal 
period was, when based upon the increase during the preceding inter- 
censal period, at the rate indicated by the arithmetical or the geo- 
metrical method. 

Geometrical method. — As previously stated, the geometrical method 
is based upon the principle of compound interest. 



14 

Assuming a decennial census, let 

P = population ill 1900. 

. P' = population in 1910. 

T = the annual increase per unit of population. 
Then the population would be — 

In 1901=P (1+r) 
In 1902 -P (l+r) 2 
In 1903=P (1+r) 3 

In 1910 (P')=P (!+?-) '' 

p— (l+r-)^° 

p- = l+r andr = yp — 1 

In practice the calculation would be made vdth the aid of a table 
of logarithms, and given the value of v the estimated population for 
any intercensal or post censal date is readily obtained. For post 
censal dates the estimated population would be — 

In 1911 =P' (1+r) 

In 1912 = P' (1+r)^ 

In 1913-P' (HTr)2 

^ift year = P' (1+r) ^ 
The registrar general of England and Wales uses the geometrical 
method for England and Wales as a whole and a modified method 
for lesser subdivisions. 



Marriage statistics are of interest because of the information they 
give regarding the social life of the people and the establishment of 
families and households, and because of the relation of marriages to 
population growth through their influence on the birth rate. Their 
consideration naturally precedes that of birth statistics. 

The data for marriage statistics are obtained by the registration of 
marriages. The common custom in the United States is to require 
persons desiring to marry to obtain first a license from a designated 
official. This hcense is presented to whoever performs the marriage 
ceremony. The person officiating is required to register the mar- 
riage. Those responsible for the completeness of marriage records 
are therefore in this country usually the clergy and justices of the 
peace. There is seldom much difficulty in securing complete records 
of marriages, and the amount and value of the information given by 
marriage statistics depend upon the nature and extent of the facts 
recorded relating to the contracting parties. 

In England and Wales marriage statistics are compiled by the 
registrar general of marriages, births, and deaths. In this country 



15 

the official responsible for tlie compilation of marriage records varies 
in tlie several States. The United States Bureau of the Census has 
compiled statistics of marriage and cUvorce in the United States from 
1867 to 1906. These were pubhshed in 1909. 

Marnage rates. — Marriage rates may be expressed as the number of 
marriages for each 1,000 population. While this method gives cer- 
tain information of a definite character and is useful for comparing 
different years of the same community and different communities of 
similar population composition, it is not useful in comparing popu- 
lations in which the proportion of single persons of marriageable 
age is not the same. For the j^urpose of comparing marriage rates, 
therefore, the more exact method is to express the rate as the number 
of marriages or persons married for each 1,000 unmarried, divorced, 
and widowed, of marriageable age, usually those over 15 years of age. 







184-5 


1850 


1855 


i860 


1865 


1870 


!&75 


1880 


1885 


1890 


1895 


!900 


1905 


1910 
















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Chart 2.— Number of persons married per 1,000 population per annum— England and Wales— 1840 to 
1910. The curve shows the mean annual rate for quinquennial periods. 



Factors influencing marriage rates. — Marriage rates are usually in- 
fluenced by economic conditions. National prosperity increases the 
rate, economic depression reduces it. For the same reasons it is 
influenced by the demand for labor and the rate of wages. The rela- 
tion of the adopted standard of living to the average v/age has a 
similar effect. In the absence of other factors, the marriage rate is 
usually a fair index of the relation of average income to standard of 
living. 

The marriage rate may also be affected by the frequency of divorce 
and remarriage. A high birth rate tends to increase the marriage 
rate in succeeding years. In communities such as minuig towns and 
new industrial centers the marriage rate may be Umited by the pres- 
ence of a relatively small number of marriageable women. 

The marriage rate in a city may be fictitiously high, due to the 
fact that many couples from the surrounding country and small 
towns may go there for the purpose of being married, returning then 



16 



to their homes. In a country affected by emigration a relatively 
largo proportion of the migrants are apt to be young men and women, 

1875 1880 1885 1890 1395 



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1905 



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Chart 3.— Bii'ths (including stillbirths), persons married, and deaths (excluding stillbirths) registered 
per 1,000 population per annum— Michigan— 1871 to 1911. 

the women frequently following after the men have become located. 
This naturally affects the marriage rate of the home country. 

Table 2. — Number of persons married per 1,000 population in certain countries, 1892 

ayidWll} 



Country or State. 


1S92 


1911 


Australian Commonwealth 


13.5 
15.7 
13.5 
15.4 
12.2 
15.1 
15.9 
18.4 
9.3 
14.9 
14.4 
12.5 
12.7 
15.4 
14.1 
19.0 
16.9 
11.4 


17.6 


Austria 


15.2 


Denmark . 


14.4 


England and Wales 


15.2 


Finland 


12.0 


France 


15.5 




15.7 


Hungary. 


18.5 




10.7 


Italy 


15.0 


The Netherlands 


14.3 




17.4 




12.5 




21.0 




13.4 




20.6 




14.2 




11.7 




18.8 




18.0 
18.6 


18.6 




20.9 







1 Taken from the Seventy-fourth Annual Report of the Registrar General of Births, Deaths, and Mar- 
riages in England and Wales, 1911, except the rates for Massachusetts, Michigan, and Connecticut, which 
were taken from the State reports. 



17 

' ■ Uses of marriage registration.— The purpose of the registration of a 
marriage is largely to protect the home and family. It furnishes 
reliable evidence upon which to base the legitimacy of children and 
the dower rights of women. 

BIRTH STATISTICS. 

Statistics of births are of interest mainly because of their relation 
to population growth, the excess of births over deaths being known 
as the "natural increase." Growth of population has been the 
object of concern to nations largely because of its effect in deter- 
mining the future military strength and the number of men available 
for purposes of offense and defense. The practically stationary popu- 
lation of France has for some time been the subject of comment, but 
with her limited territory it is a question whether the people as a 
whole are not better off with the present population than they would 
be with a larger one. More people mean greater congestion and more 
intense competition. During the last century Great Britain, Ger- 
many, Austria, and Russia have trebled in population. Had France 
done the same, she would now have nearly 80 millions of people, 
and it is doubtful whether this would have added to the happiness 
and welfare of the race. 

It is undoubtedly better to have a people proportionate in number 
to land area and natural resources than to have a teeming population 
with the consequent economic problems. It would seem more in 
keeping with modern ethics to strive for a people composed of intelli- 
gent, physically sound individuals free from disease and properly 
housed, fed, and clothed, whose da3^s furnished time for both labor 
and recreation under conditions which conduced to physical and 
mental welfare and not to deterioration, rather than to strive for 
mere numibers. 

To the health officer and sanitarian birth statistics have only casual 
interest. Birth registration, however, which furnishes the data from 
which the statistics are made, is important not only in public health 
work but in other ways as well. 

Registration in England. 

Registration of baptisms, marriages, and deaths in England dates 
back to 1538, when Thomas Cromwell, Vicar General under Henry 
VIII, issued injunctions to all parishes in England and Wales requiring 
the clergy to enter every Sunday in a book kept for the purpose a 
record of all baptisms, marriages, and burials of the preceding week.^ 
A copy of the order will be found in the appendix, page 71. 

1 "The Parish Registers of England," by J. Charles Cox. 
55256°— 14 2 



18 

August 24, 1653, Parliament passed an act taking the parocMal 
registers from the clergy and placing them in the custody of laymen 
called "parish registers" who were to record all marriages, births, 
and burials. Later this duty reverted to the clergy. 

The office of registrar general of births, marriages, and deaths was 
established in 1836 and pursuant to an act of Parliament civil regis- 
tration was begun July 1, 1837. In 1870 the registration of births 
and deaths was made compulsory, with a resulting improvement 
in the returns.^ 

Registration in the United States. 

In legislation the registration of births^ marriages, and deaths were 
formerly usualty associated and provided for by the same laws. 
Since 1900, however^ this has not been generally true in the United 
States, where the practice has developed of providing separately for 
the registration of births and deaths. 

COLONIAL PERIOD. 

In 1632 the Grand Assembly of Virginia passed a law requiring a 
miaister or warden from ererj parish to be present annually at court 
on the 1st of June and present a register of all burials, christenings, 
and marriages. 

In 1639 Massachusetts Bay colony adopted a requirement for the 
keeping of records of marriages, births, and deaths. 

In 1646 the Plymouth colony enacted a law providing that the 
clerk or someone in every town should keep a record of all marriages, 
births, and burials. 

In 1692 Massachusetts put the registration of births and deaths on 
a more definite basis by the enactment of the following law; 

Chapter 48. 

an act for the registering of births and deaths. 

For preventing of great tincertainty and inconvenience that may happen for want 
of a particular register of births and deaths — 

. Be it enacted by the Governor, Council and Representatives in General Court assembled, 
and by the authority of the same, That every town clerk within this province shall be 
and is hereby impowred and required to take an account of all persons that shall be 
born, or shall dye, within each town, respectively, and the precincts thereof, and 
fairly to register in a book their names and surnames, as also the names and surnames 
of their parents, with the time of their birth and dearth. And the clerk shall demand 
and receive the fee of threepence, and no more, for each birth, or death by him so 
registered, to be paid by the parents or others nextly related to or concerned with 
the party born or dying. And if any shall refuse ox neglect to give notice to the town 
clerk of the birth or death of any person that they are so related to or concerned for, 
or to pay for registring as abovesaid by the space of thirty days next after such birth 
or death, every person so refusing or neglecting, and being (upon the complaint of 
any town clerk) thereof convicted before a justice of the peace mthin the same county, 

1 Vital statistics, Newsholme, 1S99. 



19 

shall forfeit and pay Tinto such clerk the sum of five shillings, to be levied by distress 
and sale of the offender 's goods by warrant from such justice, if payment thereof be 
not made within four days next after conviction as aforesaid. And every town clerk 
diall give forth from the registry a fair certificate, under his hand, of persons born or 
dying in the town, to any who shall desire the same; and he shall receive sixpence and 
no more for every certificate so given. 
(Passed February 17, 1692-3.) 

POSTCOLONIAL PERIOD. 

In 1795 Massachusetts passed a law repealing the 1692 act and 
requiring parents to give notice to the town clerk of births and 
deaths of children, householders to give notice of those in their 
households, and persons in charge of institutions of those occurring 
in their respective institutions. The town clerks were requhed by 
the same law to keep a record of all births and deaths coming to 
their knowledge. In the case of births the date of birth and the 
names of the parents were to be recorded. A penalty of $1 was pro- 
vided for failure to report a birth or death. 

In 1842 Massachusetts passed the following act providing for the 
registration of births, marriages, and deaths: 

An Act relating to the registry and returns of births, maiTiages, and deaths. 

Be it enacted by the Senate and Souse of Representatives, in General Court assembled, 
and by the authority of the same, as folloivs: 

Sec. 1. The clerks of the several towns and cities in the Commonwealth shall, 
annually, in the month of May, transmit to the secretary of the Commonwealth a certi- 
fied copy of their record of the births, marriages, and deaths of all persons within their 
respective towns and cities, which may come to their knowledge; slull state the num- 
ber of births and marriages, and the number of deaths, with the name, sex, age (and if 
an adult male, the occupation), and the names of the diseases of which all persons have 
died, or are supposed to have died, together with the cause or causes of the death of all 
such deceased jjersons, so far as they may be able to obtain a knowledge of the same 
fi'om physicians or others; and any clerk who shall neglect to make such return, shall 
be liable to a penalty of ten dollars, to be recovered for the use of any town or city 
where such neglect shall be proved to have existed. 

Sec. 2. The secretary of the Commonwealth shall prepare and furnish to the clerks 
of the several towns and cities in this Commonwealth, blank forms of returns, as herein 
before specified, and shall accompany the same ^vith such instructions and explana- 
tions as may be necessary and useful; and he shall receive said returns, and prepare 
therefrom such tabular results as will render them of practical utility, and shall make 
report thereof annually to the legislature, and generally shall do whatever may be 
required to carry into effect the objects of this act, and of the several provisions of the 
Revised Statutes not inconsistent with this act. (Approved by the Governor, Mar. 
3, 1842.) 

In 1844 ]Massachusetts passed another law amplifying the preceding 
and requiring the town clerks to number the births registered and to 
record them in the order in which received, showing in separate 
columns the date of birth, place of birth, name of child, sex of child, 
name and surname of one or both parents, occupation of father, 
residence of parents, and the time of making the record. Marriages 



20 

were also required to be numbered and recorded in tlie order received, 
the record to sliow the date and place of marriage; the name, resi- 
dence, and official station of the person performing the ceremony; 
the names and surnames of the contracting parties and the residence, 
age, civil status, occupation, and the nam.es of the parents of each; 
and the time when the record was made. Deaths were likewise to 
be numbered and recorded in the order received, the records to show 
the date of death; the name, surname, sex, civil (mpaital) status, 
age, occupation, place of death, place of birth, and names of parents 
of the decedent; the cause of death; a,nd the time the record was 
made. 

The school committee of each town and city was to ascertain an- 
nually in May the births which had occurred during the preceding- 
year and to report them with all required data to the town clerk. 
Persons solemnizing marriages were to keep proper records and make 
returns to the town clerks once a month. Sextons or other persons 
having charge of burial grounds were to keep records of burials and 
make returns monthly to the town clerk. 

The law of 1844 placed the responsibility for the registration of 
births upon the school committee, for the registration of marriages 
upon the persons officiating, and for the registration of deaths upon 
persons in charge of burial grounds. 

Most of the other States have from time to time passed laws requir- 
ing the registration of births. Many of these laws have been faulty 
and incapable of enforcement. The returns have also suffered in 
most instances from the absence of particular efforts at enforcement 
so that in very few locahties have the records been at all complete. 

RECENT DEVELOPMENT. 

The American Medical Association has for many years taken cog- 
nizance of the need for improved registration of births, marriages, 
and deaths. As early as 1846 a committee was appointed to consider 
ways and means for improving the registration of births, marriages, 
and deaths. In 1855 the following resolutions were adopted by the 
association: 

Resolved, That the members of the medical profession throughout the Union be 
urgently requested to take immediate and concerted action for petitioning their 
several legislative bodies to establish offices for the collection of vital statistics. 

Resolved, That a committee of one from each State be appointed to report upon a 
uniform system of registration of marriages, births, and deaths. 

Of recent years merited attention has been given to the subject 
of bkth registration by the Bureau of the Census, the American 
PubHc Health Association, the American Medical Association, and 
other similar bodies. The recently estabhshed Children's Bureau of 
the Federal Government has, since its organization, been especially 
active in urging the need of better reoistration. 



21 

A model bill for the registration of births and deaths recom- 
mended for enactment by the several State legislatm-es has been 
drafted and indorsed by the American Medical Association in con- 
sultation with representatives of the Bmeau of the Census, the 
Children's Bureau, the American Pubhc Health Association, the 
American Bar Association, and a number of other organizations and 
societies national m scope. (For copy of model bill see appendix, 
pp. 83-92.) The essential features of this law have been adopted 
by a number of States. It is important that other States should 
also enact it, for it is without question as effective a law as any 
that has been proposed for adoption in this country. It is also 
highly desirable that the laws of the several States on the subject 
be uniform, if the Bureau of the Census is to compile the records 
for statistical purposes. The power to legislate on such matters 
resides with the individual States. The only means the Bureau 
of the Census has of preparmg national bhth statistics is to com- 
pile the records registered in the several States under State laws. 
This is done by makmg copies of the birth certificates registered 
in the various States and from these copies taking the data for 
statistical tabulations. The adoption of a uniform law would 
therefore have distinct advantages, even if it were possible for State 
legislatures individually to draft better ones. 

Source of data. — While the data from which population statistics are 
derived are obtamed by direct enumeration, the data from which 
birth statistics are compiled are gotten by registration. The usual 
requirement is that whenever a child is born either the attending phy- 
sician or midwife, or, in their absence, the parents or the head of the 
household in which the birth occurred, shall register with an official 
designated for the purpose certain information regarding the chfid and 
its parents. 

Nature of information secured hy registration. — The information re- 
quired to be registered concernmg each child born usually includes 
certain facts relating to the child and the circumstances of its bkth, 
together with certain items concerning the parents. The essential 
facts are the name of the child, its sex, date and place of birth, and 
whether born alive or stiUborn, and the names and residence of the 
parents. There are many other items of information concerning births 
which are of the greatest value and serve various purposes, such as the 
age, color, nativity, and occupation of the parents, whether the child is 
a single birth, a twin, or triplet, and whether legitimate or illegitimate. 
These facts are usually required to be stated. 

The items registered serve two principal purposes. They serve, 
first, to identify the child and to establish its age and parentage, and, 
second, to furnish statistical data. 



22 

While in the enumeration of the population the original observer, 
upon the accuracy of whose work population statistics largely depend, 
is the census enumerator; in birth registration the original observer, 
upon whom dependence must be placed, is usually the physician 
attendmg at the birth, sometimes the midwife, and in the absence of 
these the parents. 

Bu'ths are usually required to be registered with an official ap- 
pointed for the purpose and known as a registrar. Customarily it is 
the same official with whom deaths are registered. Not uncommonly 
a small fee is paid to the person making the registration or filling out 
the certificate. This custom, however, is likely to create in the 
minds of many the idea that the registration is a matter of discretion — 
that if the fee is not wanted there is no compulsion to file the certifi- 
cate and that the forfeiting of the fee annuls the obligation. This is 
especially true in the United States, where phj^sicians and midwives 
have in many instances not yet come to realize that the importance 
of proper registration may mean so much to the child and its parents 
that no accoucheur has completed his task nor fulfilled his obligations 
to the child and its mother until an accurately filled out certificate has 
been filed with the registrar. The failure to file such a certificate is 
such a neglect of the mterests of both patients, the child and the 
mother, that it would seem proper to class it as malpractice. 

Standard hiriJi certificate for United States. — The standard form of 
birth certificate approved by the Bureau of the Census and recom- 
mended for use in the United States appears on page 93 of the appen- 
dix. The dimensions of the certificate as used are 6| by 7|- inches. 

Frequently the child is not named until some time after birth, so that 
it is impossible to insert in the certificate the full name of the infant. 
To meet this difficulty the Bureau of the Census recommends the use 
of a ''supplemental report of birth" which is to be filled in after the 
child has been named and filed with the registrar, who attaches it to 
the original certificate. See Appendix, p. 93. 

Birth Rates. 

There are several ways of expressing the birth rate. Each method 
of statement gives information not given by the others. 

Rate per 1 ,000 population. — The birth rate may be expressed as the 
number of bu'ths occurring during a year for each 1,000 of the popula- 
tion. This is known as the crude birth rate, and is based upon the 
total estimated mean population for the year — that is, for the calendar 
year, the population estimated as of July 1. The crude birth rate 
shows the net result to the community of the several factors governing 
reproduction- — the number of women of child-bearing age, the number 
of those who are married, the frequency of illegitimacy, etc. In con- 



23 

junction with the crude death rate it shows the ratio at which the com- 
munity is reproducing itself by natural increase. It is a quite satis- 
factory basis for comparing the bnth rate of different years for the 
same community or that of different communities having populations 
of similar composition. It is unsatisfactory for the comparison of 
populations havmg different proportions of females of child-bearhig 
age or of married women — a mining town or new industrial center 
may have comparatively few women ; a fashionable residential distric t 







1845 


185Q 


1855 


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1865 


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Chart 4.— Births and deaths (exclusive of stillbirths) per 1,000 population per annum— England and 
Wales— 1840 to 1910. The curve shows the mean annual rates for quinquennial periods. 

may have a relatively large female population, most of which consists 
of unmarried servants. 

Boie 'per 1,000 women of cJiild-hearing age. — Birth rates maybe 
expressed as the number of births occurring during the year per 1,000 
women of child-beaiing age. For this purpose the female popula- 
tion between the ages of 15 and 45 years as determined by census 
enumeration, or by estimation for interceiisal and post censal years, 
is taken. The proportion of women of these ages in the population 
having been ascertained by a census, the same relative proportion 
is assumed to be maintained until a succeeding census shows a change. 



24 

This method gives rates that furnish a much better basis for the 
comparison of different communities, in as much as it gives the births 
in proportion to the number of potential mothers. It is not, however, 
satisfactory under all conditions, and the method next described 
yields more useful information. 

Rate of legitimate hirtlis per 1,000 married women of child-hearing 
age {15 to 4.Ji.or 15 to 4-9 years of age) and of illegitimate hirtlis per 1,000 
unmarried women of child-hearing age. — In different communities 
the proportion of married and single women may differ considerably 
and consequently comparison of their crude birth rates or of rates 
based on the number of women of child-bearing age would jdeld con- 
paratively little useful information. The proportion of married 







1855 


I860 


1865 


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Chart 5.— Births and deaths (exclusive of stillbirths) per 1,000 population per annum— Massachusetts — 
1S50 to 1910. The cun^e shows the mean annual rate for quinquennial periods. 

women in industrial communities is usually considerably larger than 
it is in residential suburbs, where there are greater numbers of 
female servants. To make allowance for these differences in popula- 
tion composition the most useful method of stating the birth rate is 
in terms of the number of legitimate births per 1,000 married women 
of child-beariaig age (15 to 44 years or 15 to 49 years) and the number 
of illegitimate births per 1,000 unmarried women of this age. 

Sources of Error in Birth Statistics. 

The principal sources of error in birth statistics are to be found in 
defective registration. There is no reliable check by which the failure 
tcf register births can in all cases be detected. In many foreign coun- 
tries the people have become accustomed to register births and ap- 
parently their returns are quite complete. The registration of 



25 . 

illegitimate births, however, is alwaj^s less complete than that of the 
legitimate. In the United States the people, as a whole, have in 
most sections not become accustomed to the registration of births. 
This is undoubtedly due in part to a rapidly changing population 
continually receiving large numbers of immigrants from various 
foreign countries — immigrants who are ignorant of our registration 
laws and have little opportunity of learning their requirements — and 
in part to the abserice of effort by the authorities to enforce the laws. 
As checks upon the completeness of birth registration registrars 
frequently use the death returns of young children and especially of 
mfants, checking up each recorded death with the birth records to 
see whether the birth of the child had been registered. The notices 
of births appearmg in newspapers are also often used for the same 
purpose. If in cities dealers were required to keep a record of all 
sales of baby carriages, cribs, and high chairs tiiis might be of use as a 
further check until the population shall have become thoroughly 
used to registration. Also, if aU. christenings were required to be 
notified by those officiating, this too would be of assistance. 

Uses of Birth Registration and Statistics. 

Birth statistics are of use in ascertaining the natural increase of the 
population (excess of births over deaths). They also give valuable 
information regarding the effective fertihty or fecundity of the race 
and of the frequency of illegitimacy. These matters are of interest 
to the economist and the statesman. The possession of birth statis-. 
tics also furnishes the basis for the present accepted means of stating 
the infant mortality rate, as wiU be explained later. The data from 
which the statistics are made, the registered births, are on the other 
hand of value to the community in many ways, and to the health 
officer among others may be especially useful. Some of the uses 
wUl be enumerated. 

Legal record. — The registration of a child's birth forms a legal 
record that is frequently useful and may be of the greatest importance. 
It establishes the date of birth and the child's parentage and legiti- 
macy. It may be required to establish the child's age for attendance 
at public schools, for permission to work in States where children 
below a certain age are not allowed by law to be employed; to show 
whether a girl has reached the age of consent, whether individuals 
have attained the age when they may marry without the parent's per- 
mission; to estabhsh age in connection with the granting of pensions, 
miUtary and jury duty, and voting. It may be necessary in con- 
nection with the bequeathing and inheritance of property or to 
furnish acceptable evidence of genealogy, and in fact may be impor- 
tant and useful in possible events too numerous to mention. 

Uses in 'public health administration. — Registration of births shows 
where the babies are and makes possible such observance and pro tec- 



, 26 ' 

tion as the health department desh-es to extend. With bu'th regis- 
tration it would be possible for the health authorities to see that the 
babies are vaccinated against smallpox. This is on© of the uses made 
of registration in England. It would also be possible to see that the 
babies in poor famiUes have proper food and adequate attention. The 
observation of infants under 2 weeks of age would bring to hght some 
cases of ophthalmia which otherwise might cause serious injury to 
vision and at times total blindness. 

Table 3. — Birth rates {exclusive of stillbirths) per 1,000 population in certain countries, 

1886 and 1911.1 



Country or Stat«. 


18S6 


1911 




35.4 
38.3 
32.4 
32.8 
35.3 
23.9 
37.0 
45.6 
23.2 
37.0 
34.6 
33.1 
31.2 
42.2 
32.9 
42.0 
36.7 
29.8 

2 22.2 

25.4 

2 21.3 


27.2 




31.4 




26.8 




24.4 




29.1 




18.7 




28.6 




35.0 




23.2 


Italy 


31.5 






27.8 




26.0 




25.9 




43.0 




25.6 




36.2 




31.2 




23.8 




24.8 




25.7 




23.0 







1 Taken from the Seventy-fourth Annual Report of the Registrar General of Births, Deaths, and Mar- 
riages in England and Wales, 1911, except the rates for Connecticut, Massachusetts, and Michigan, which 
were taken from the State reports. 

- Includes stillbiiths. 

Factors Influencing Birth Rates. 

Birth rates are directly influenced by the number of women, and 
particularly of married women, of child-bearing age in the population. 
The child-bearing period of life for women may be considered as that 
between the ages of 15 and 49 years; the ages between 25 and 44 
years are for most races of the north temperate zones, however, 
those mainly productive. 

The economic and social status of the population may also affect 
the birth rate. In many countries at present the poorer families have 
considerably more children per family than have the weU-to-do; in 
fact to some extent the number of children per marriage seems to be 
inversely as the family income. On the other hand, to a degree poor 
economic conditions are hable to discourage or delay marriage, so 
that married couples are relatively fewer and older when married, 
with fewer resultmg offspring. The adoption of a more expensive 
standard of hving may produce the same results as depressed eco- 
nomic conditions, fewer and delayed marriages. 



27 

The birth rate is also affected by the habits and customs of the 
people, by their desire to have children or their desire not to have 
them. Also a high infant death rate is usually accompanied by a high 
birth rate and, conversely, a low infant death rate by a lov/ birth rate. 

MOMBIDITY STATISTICS. 

Morbidity statistics are the statistics of sickness and disease. 
They show the occurrence of diseases and their relative prevalence in 
different locahties and at different times. They differ from mortahty 
statistics in that as relates to disease, mortality statistics are the 
statistics of fatal cases only, while morbidity statistics niclude all 
cases. 

In the life of the mdividual, after birth the next event included in 
vital statistics which usually occurs is sickness. Disease has perhaps 
a greater influence in determmmg the happmess and efliciency of the 
individual and of the community than any other factor. It also has 
a direct bearing on the individual's longevity even when in itseK not 
fatal, for every attack of sickness probably does some injury and 
leaves the huuian machine impaired to a degree. 

In speaking of the usefulness of morbidity registration, Farr has 
said : 

It will be an invaluable contribution to therapeutics, as well as to bygiene, for it 
will enable the therapeutists to determine the dui-ation and the fatality of all forms of 
disease under the several existimg systems of treatment in the various sanitary and 
social conditions of the people. Illusion will be dispelled, quackeiy, as completely 
as astrology, suppressed, a science of therapeutics created, •suffering diminished, life 
ehielded from many dangers.^ 

Morbidity statistics have not evolved apace with those of births, 
marriages, and deaths. This is due to the different purposes they 
serve. The branches which have to do directly with the growtn of 
population were first developed, probably because of the need of the 
information which they gave in connection with taxation and military 
enlistment. IMorbidit}'^ statistics, on the other hand, are contem- 
porary with our comparatively recently acquired knowledge of the 
causes of diseases and their manner of spread. Their need has been 
felt only with the advent of present day pubhc health administration, 
which in turn has been activated in large measure by the story of the 
causes of death told by mortality statistics. 

Morbidity statistics had their origin in the requirement of the notifi- 
cation of cases of certain dreaded diseases, notably smallpox. With the 
appointment of health officers and the establishment of health depart- 
ments .the notification of other diseases has been requhed. As knowl- 
edge of the causes of diseases and their manner of spread has been 
obtained and health departments have been faced with the respon- 

1 Cited by Newsholme, Vital Statistics, 1899. 



sibility of controlling maladies found to be preventable, the list of 
notifiable diseases has grown, for those responsible for public health 
administration have found that it is impossible to effectively control 
a disease mthout prompt information of when, where, and under what 
conditions cases of the disease are occurring. No epidemiologist 
would think of attempting to control an outbreak of yellow fever or 
cholera without inaugurating a dependable system whereby he would 
receive prompt and accurate information of the occurrence of cases. 
It is just as impossible to effectively control tuberculosis, typhoid 
fever, scarlet fever, industrial lead poisoning, or any other preventable 
disease without a knowledge of the occurrence of cases. 

The requirements for notification of the preventable diseases and 
the extent of their enforcement may be taken as an index of the intelli- 
gence and efficiency of health administration in a community. 

Morbidity Statistics in England and V/a!es. 

In England beginning with the year 1911 the medical officer of the 
local government board has compiled statistics of the incidence of the 
diseases notifiable in England and Wales. These diseases are small- 
pox, typhus fever, scarlet fever, diphtheria, typhoid fever, puerperal 
fever, erysipelas, plague, cholera, relapsing fever, tuberculosis, pul- 
monary tuberculosis (added Jan. 1, 1912, all forms made notifi- 
able Feb. 1, 1913), cerebrospinal fever (added Sept. 1, 1912), and acute 
poliomyelitis (added Sept. 1, 1912). The local sanitary officers are 
required by a general order of the local government board, promul- 
gated December 13, 1910, to transmit to the medical officer of the 
board each Monday a statement of the cases notified to them during 
the preceding week. The medical officer of the local government board 
is the chief sanitary officer for England. Statistics of births, mar- 
riages, and deaths, on the other hand, are compiled in the office of the 
registrar general. 

The experience leading to the present system for morbidity reports 
in England and Wales was similar to that through which the United 
States is now passing. Soon after the establishment of the civil 
registration of deaths in England in 1837 it became evident that a 
record of fatal cases (deaths) only did not give the kind of information 
necessary for the control of disease and that sanitary officials must 
have knowledge of the occurrence of the nonfatal as well as of the fatal 
cases, and that this information should be received early in the course 
of the disease, for when received after the termination of the case it 
has little other than statistical value. Various men, societies, and 
associations advocated at different times plans for the notification of 
sickness throughout the country. The British Medical Association 
as far back as 1865 made repeated efforts to have adopted a uniform 
system for morbidity reports. 



m 

Morbidity Statistics in Russia. 

In Russia S3,nitary regulations adopted in 1905 require that all 
physicians, whether engaged in private practice or in Government 
service, shall forward to the local sanitary inspector havmg jurisdic- 
tion a monthly report of patients treated by them both in private 
practice and m hospitals, the reports for the patients in private prac- 
tice and those in hospitals to be made separately. In addition to this 
every case of infectious disease is to be reported at once. A heavy 
penalty is unposed for failing to report. Every hospital and clmic is 
also required to keep a detailed record of its patients and report regu- 
larly to the sanitary inspectors. The data received by the local sani- 
tary officials in the monthly reports from hospitals and practitioners 
are compiled and forwarded annually to the chief sanitary inspector 
of the ministry of the interior on forms printed for the purpose. The 
chief sanitary inspector at St. Petersburg compiles these reports of the 
occurrence of sickness throughout the empire and publishes them 
annually. 

The sickness records for Russia include all parts of the empire. 
Among the infectious diseases for which morbidity statistics are com- 
piled are smallpox, scarlet fever, diphtheria, measles, whooping cough, 
influenza, typhus fever, typhoid fever, dysentery, cholera nostras, 
Asiatic cholera, epidemic gastroenteritis, mumps, erysipelas, septice- 
mia and pyemia, rheumatic fever, croupous pneumonia, tuberculosis, 
malaria, scabies, trachoma, syphilis, soft chancre and gonorrhea. 
Statistics are also compiled for mental diseases, traumatic affections, 
and vaccinations for smallpox. 

Morbidity Statistics in the United States. 

Advocated hy American Medical Association aTid others. — The need 
of havmg mformation of the prevalence and geographic distribu- • 
tion of diseases has been realized by physicians in the United States 
for many years, and the subject has repeatedly come before the 
American Medical Association m one form or another. At the meet- 
ing m 1855 the following resolution offered by Dr. J. W. Thomson 
was adopted: 

Whereas few subjects of greater interest and importance could be presented to the 
consideration of the American Medical Association, now representing most cf the 
States and Territories of the Union, than the attainment of a correct medical topot 
graphy of each, with a history of its prevailing diseases, and most successful treatment 
of the same : Therefore be it 

Resolved, That with this view and conviction, this associatiou appoint a special com- 

mittes for each State and Territory represented, of members, whose duty it shall 

be to report upon its medical topography, epidemic diseases, and the most successful 
treatment thereof, and that the same shall continue to hold their office for three years. 



30 

Resolved, That aa other States and Territories, not now represented, become so by- 
delegates duly appointed to this national association, similar committees shall be 
appointed for like purposes, and that they also shall hold their office |or three years. 

Resolved, That in the appointment of gentlemen of education and experience in the 
affairs of their own State, we have the best guarantee that the important objects we 
seek will be more satisfactorily accomplished, and the profession as well as the public 
interest thereby better served. 

Resolved, That the committees heretofore appointed by this association at its session 
in Charleston for a similar object be, and the same are hereby, discharged. 

At this same meeting Dr. J. G. Orton introduced a resolution sup- 
plementing the preceding. The resolution, which appears not to 
have been adopted, was in part as follows : 

Resolved, That each county medical society, or (in parts of the country where such 
has not been established), any duly organized medical association, be requested to 
amend its constitution by attaching theretmto the following article: 

■"It shall be the duty of each member of this society to keep a faithful record of the 
diseases which may fall under his observation during each month, according to the 
classification adopted by this convention in May, 1847, stating the age and sex, occu- 
pation and nativity of the patient, the average duration of the disease, and finally, 
their recovery or death, and to report the same in writing to the secretary, on or before 
the first day of February of each year, who shall transmit a digest thereof to the State 
Medical Society and also to the appropriate committee appointed by the American 
Medical Association for its reception. " 

Resolved, That each incorporated hospital, infirmary, and asylum be invited to fur- 
nish a copy of their annual reports for tJie use of the committees of their respective 
States. 

Resolved, That the State committees appointed by this association to report on the 
prevailing diseases of their respective localities, shall receive and arrange a digest of 
the reports transmitted to them by the secretaries of the various county societies, and 
report the same at the annual meeting of this association. 

In 1859, Dr. W. C. Rogers, in an address on "The registration of dis- 
eases"^ stated: "The necessity for a system of registration has long 
been felt. " He then cites the foUowmg quotation from an editorial 
in the British Medical Almanac of 1837 : 

The first step in medical statistics, after having determined the mortality, is to ascer- 
tain the number of attacks of sickness at different ages, to which a population is liable, 
and the numbers constantly ill. 

First developed in Massachusetts. — In 1874 the State Board of 
Health of Massachusetts inaugurated a plan for the weekly volun- 
tary notification of prevalent diseases. A letter was sent in No- 
vember, 1874, to 168 physicians in the State, asking them to report 
weekly. One hundred and fifteen physicians agreed to do so. In 
1875, 79 additional physicians agreed to report. The letter solicit- 
ing the assistance of the physicians is of special interest because it 

1 Transactions Medical Society State of New York, 1SS9, p. 202. 



31 

represents one of the earliest and most important steps in the sys- 
teDiatic collection of morbidity reports. The letter follows: 

Commonwealth of Massachusetts, 

State Board of Health, 

Boston, November 1, 1874. 
Dear Sir: The State board of health is very desirous of getting weekly infonna- 
tion of the diseases prevalent in all parts of Massachusetts. The object is certainly 
one of great importance — positive knowledge of the health of the people, as well as 
of the diseases which, at any time and place, are present, or which threaten to ex- 
tend as epidemics. 

lu order, however, to attain this end the board will need the cooperation of a large 
and select number of physicians, in full general practice, in various parts of the State. 
We, therefore, take the liberty of asking whether you will consent to be one of tliis 
number — ^to report weekly during the next year (1875) the diseases prevalent in your 
vicinity. The inclosed sample postal card will indicate the proposed method; it will 
be observed that an endeavor has been made to rediice to the minimum the expendi- 
ture of time and trouble incident to the service asked of busy medical men. 

The board has appointed Dr. F. W. Draper, of Boston, to be the registrar of this new 
bureau of health correspondence. He will compile from the returns received a concise 
weekly bulletin of prevalent diseases to be reported to the secretary of the board, and 
published, with appropriate comments, for the information of the people. At the 
endoitheyearasummary of the accumulated observations will be prepared for pub- 
lication in the annual report of the board. 

If the board is successful in securing the cooperation of physicians in the accom- 
plishment of this plan, the practical results will be of essential value not only to the 
State at large, but to private individuals. To medical men, in particular, such a weekly 
synopsis of prevalent diseases would be possessed of obvious interest. It is not out 
of place to remark also that the present scheme is the first practical attempt in any 
part of the world to make a systematic weekly registration of diseases. It is hoped that 
you Avill consent to assist the board in executing a purpose which is capable of being 
developed to very useful ends. If you will please to signify your willingness to un- 
dertake the service alluded to, the proper blanks will be forwarded. 
We have the honor to be, very respectfully, yours, 

Henry I. Bowditch, 
David L. Webster, 
J. C. Hoadley, 
Richard Frothingham, 
T. B. Newhall, 
R. T. Davis, 
Chas. F. Folsom, 
Members of the State Board of Health. 



32 



■ The information called for by the postal card form referred to and 
its typographical arrangement are shown by the following repro- 
duction : 

Massachusetts Report Card, 1874. 

Report of diseases prevalent during the iveeh ending 
Saturday, , 1875. 



'03 « n ' 



o°-3e 



•a 



-w- g 2 6 -« 



O " o iS S 



g g o oT " 
03 -2 ^ .g © 

C! ro ^^ 4J CO 

■^ > e>0 03 

<c a 3 c3 a> 



^3 § gj'cS.B 



Bronchitis 

Cholera Infantum 

Cholera Morbus 

Croup (Membraneous) . 

Diphtheria 

Diarrhoea 

Dysentery 

Influenza 

Measles 

Pneumonia 

Rheumatism 

Scarlatina 

SmaU-pox 

Typhoid Fever 

Whooping-cough 



Mild. 



Remarks . 



-M. D. 



Dr. F, W. Dra,per was placed in charge of the work and made 
registrar of the bureau of health correspondence. The opening 
paragraphs of his first report were as follows : 

The desirability of a trustworthy method for the registration of prevalent diseases 
is undisputed. Sanitarians have repeatedly expressed the want, but have failed 
hitherto to realize its fulfilment. They know how much greater would be their power 
to protect the public health if data of the local development and progress of disease 
were promptly afforded to them. They recognize the fact that the utility of such a 
registration is amply illustrated in the control which boards of health exercise during 
invasions of smallpox, prompt measures of prevention by isolation being thereby 
made possible for the defense of the entire community. In a still broader sense, 
they see the great advantage which would result from the opportunity to study the 
rise and fall of epidemics, and the development of diseases whose cause lies in local 
and preventable conditions. 



33 

Hitherto health authorities have relied on the registration of deaths as affording 
a basis for their active operations in behalf of the public welfare, as -n-ell as for generali- 
zations in sanitary science. A persistently high rate of mortality is an indication 
that sometliing is wrong in the sanitary condition of the community reporthi" it- 
it is a signal that so far as that region is concerned, influences are at work which demand 
speedy investigation and, if it be possible, prompt removal. Therefore the registra- 
. tion of mortality has always been acknowledged as an invaluable adjuvant to sanitary 
administration. 

But it is obvious that the death rate does not represent the actual state of the public 
health, the real amount of sickness, or its real character at any given time in any 
community. An entire hamlet may be smitten by an epidemic which makes no 
impression on the l)ills of mortality. The schools of a township may be forced to take 
an unseasonable vacation by a general invasion of whooping cough, which may cause 









J885 








1890 








1895 








1900 








1905 








1910 




















' 














































7000 






































































































\. 




















6000 












































k. 




























































\ 


















5000 


































































































i 








\ 
















4000 






































1 




























































1 








\ 
















300O 






































1 




























































1 
























2000 






































1 














A 


\ 












































/ 












/ 


/ 


\ 








ipoo 






































1 












/ 














































ff 
























/' 
















u 


s^ 


=™ 


s= 


_g. 


^ 


b 




„ 


__ 




/] 



























Chart 6.— Smallpox— Number of cases notified per amium in Michigan from 1883 to 1912. 

a comparatively small number of deaths. Mild scarlatina, or diphtheria, or even 
smallpox may sweep through a village and be the occasion or only a few funerals. 
On the other hand, an exceptionally severe outbreak of infectious diseases may be 
attended with a fatality out of all proportion to the number sick, and thus become the 
source of erroneous inferences. So that it seems eminently desirable that a registra- 
tion of diseases should in some way be put into operation, not to take the place of 
mortality registration, but to supplement it. 

Massachusetts and Michigan were pioneers in the collection of 
information regarding the prevalence of disease. 

In 1884 Massachusetts passed a law rec|uirmg householders and 
physicians to report immediately to the selectmen or board of health 
of the town all cases of "smallpox, diphtheria, scarlet fever, or any 
other disease dangerous to the public health." Penalty for failure 
on the part of the householder was made a fine not exceeding $100. 
The penalty for failure of physicians was a fine of not less than 
nor more than $200. 

55256°—!^. 3 



34 



Early development in Michigan. — Tlie plan which the Mx^ssachusetts 
State Board of Health adopted in 1874 of furnishing postal-card 
blanks to voluntary correspondents for the pui^ose of collecting 
weekly information of the prevalence of disease was "adopted by the 
Michigan State Board of Health in 1876. In its annual report for 
the year the State board of health in referring to the matter states 
"A knowledge of the nature and extent of prevalence of at least the 
several prominent diseases throughout the State has from the first 
organization of the board been considered desirable.'' 

In 1883 Michigan passed a law requiring householders, hotel 
keepers, keepei^ of boarding houses, or tenants, to report immediately 



1885 



1890 



1895 



1900 



1905 



1910 




Chart 7.— Smallpox— Number of cases notffied per annum for each d eath registered— Michigan— 

1883 to 1912. 

to the health officer or board of health all cases of "smallpos, cholera, 
diphtheria, scarlet fever, or any other disease dangerous to the public 
health."^ The notice was to state the name of the patient, the name 
of the disease, and the name of the householder or hotel keeper giving 
the information; also the address where the patient was to be found. 
Physicians were similarly requu-ed to report cases, and when the 
physician reported a case the householder or hotel keeper was not 
required to do so. 

The Michigan law seems to be the first one looking to the compre- 
hensive collection of information in regard to the prevalence of 
disease, and for a number of years the work was carried on with 



35 



intelligence and perseverance under the able supervision of Dr. Henry 
B. Baker, secretary of the State board of health. Dr. Baker was 
truly a pioneer in this work and many years ahead of his time in his 
appreciation of its importance. 

Present status. — In the United States the authority to require the 
notification of cases of sickness resides in the respective State legis- 
latures. In some of the States authority has been given to the State 
boards of health to cover the subject by regulations. In most 
instances local authorities have the right to supplement the State 
requirements by such additional ones as may be needed. The laws 







1885 








i890 








1895 








1300 








1905 








1910 




































































,40 


























































































































35 


























































































































'30 
























,/ 


^ 


























































/ 






































25 




































y 


— 




































/ 


s 














y 


^' 


\, 


/ 






\ 




















;eo 












^ 


/ 


S 


^ 












/ 




A 


f 








k 










/ 


















/ 






\ 


























\ 








/ 










15 












/ 






\^ 
































^ 


/ 












/ 


\ 




/ 






































/ 














10 




V 


,\ 




r 
















































































































5 
















































































































































































_ 


^ 







Chaet 8. — Scarlet fever — is umber of cases notified per annum for each death registered— Michigan— 1884 

to 1910. 

and regulations of the several States differ widely, as do also the 
efforts made to enforce them. 

The common and most general plan is to require that the original 
report be made by the physician to the local health officer imme= 
diately on diagnosis of the case. The local health officer forwards to 
the State health department, either immediately or at intervals, a 
transcript or a summary of the notifications received by him. In a 
number of States these reports by the local health departments are 
made to the State authorities daily, in some weekly, in one State 
twice a month, in several States monthly, and in a few States at 
longer intervals. In the States in which the reports are made daily 
the State health department is in a position to keep constantly 
informed regarding the prevalence of the notifiable diseases. The 
same is in less measure true when the reports are made weekly. 



36 

■When the reports are made at longer intervals the current value of 
the information to the State department is largely lost. 

In two States physicians are required to report the notifiable 
diseases directly to the State health department. This, in effect, 
makes the State health officer also the local health officer and respon- 
sible for the control of the notifiable diseases, the control of disease 



1 




1890 








1895 








1900 








1905 








1910 
















' 






























































300 










































































1 
















































j- 














/ 






























































1 
















































250 


— 


— 










1 
























































1 






























































/ 






























































1 






























































[ 
















































200 








r 


















































































































































































ISO 






















































































































































































































































100 
















] 
































































k 










































— 




\ 
















\ 








































•^ 






\ 






















































50 








\ 


/ 






















"** 


^ 










/ 
























































Ss 


^ 


/ 













































































































































































































Chakt 9. — Measles— Number of cases notified per annum for each death registered — Michigan — 1800 to 1010. 

and the notification of cases being inseparable, the latter giving the 
necessary information by which to direct action in the former. 

In some States the laws relating to morbidity reports specify that 
cases of certain classes of disease shall be notifiable. These classes 
have been variously stated, the wording being in some instances that 
''all cases of contagious or infectious diseases dangerous to the pubfic 
health shall be reported," in others "aU communicable diseases," or 
"aU contagious diseases," or ''all diseases dangerous to the pubfic 
health." When the requirements have been stated in general terms 
in this way their enforcement has been especially difficult unless the 
diseases included have been specifically enumerated. 



37 



The Notifiable Diseases. 

The followmg-named diseases are those specified by the various 
Stats requirements, with the number of States in which each is 
notifiable: • 



Actinomycosis 

Anthrax 

Barber's itch 

Beriberi 

Cancer. 

Cerebrospinal meningitis 

Chagres fever 

Chicken-pox 

Cholera (Asiatic) 

Colibacilosis 

Dengue 

Diphtheria 

Dysenteiy 

Echinococcus disease 

Epidemic dysentery 

Amebic dysentery 

Erysipelas 

FaAms 

FUariasis 

Follicular conjunctivitis 

German measles 

Glanders 

Gonococcus infection 

Hookworm disease 

Impetigo contagiosa 

Leprosy 

Malaria 

Malta fever 

Measles 

Mumps 

Ophthalmia neonatorum 

Paragonimiasis (lung-fluke disease). 

Paratyphoid fever 

Pellagra 

Plague 

Pneumonia 

Poliomyelitis 

Puerperal fever 



6 

15 

1 

3 

3 

23 

1 

21 

41 

1 

8 

46 

3 

1 

6 



1 
1 
8 

13 
5 
7 
1 

28 
9 
1 

31 
7 

14 
2 
3 
8 

28 

11 



Pi.abies 

Relapsing fever 

Rocky Mountain spotted fever. . 

Scabies , 

Scarlet fever 

Septic sore throat 

Smallpox 

Syphilis 

Tetanus 

Tetanus infantum 

Trachoma 

Trichinosis 

Tuberculosis: 

All forms 

Communicable forms 

Laryngeal 

Pulmonary 

Typhoid fever 

Typhus fever 

Whooping cough 

Yellow fever 

Venereal diseases 

Mental deficiency (including 

lepsy) 

Occupational diseases: 

Arsenic poisoning 

Brass poisoning 

Carbon monoxide poisoning 

Lead poisoning 

Mercury poisoning 

Natural gas poisoning 

Phosphorus poisoning 

Wood alcohol poisoning 

Naphtha poisoning 

Bisulphide of carbon poisoning.. 

Dinitrobenzine poisoning 

Caisson disease (compressed-air 
illness) 



epi- 



10 
4 
3 
1 

45 
I 

49 
G 
8 
1 

11 
6 

29 

1 

6 

10 

35 

31 

27 

35 

2 



12 
5 
1 

14 

12 
1 

12 
5 
1 
1 
1 

12 



The Model State Law for Morbidity Reports. 

Since eacli State has exchisive authority within its jurisdiction over 
the requirements for the notification of disease, any comi:)rehensive 
plan that may be developed for morbidity reports and morbidity 
statistics must be the result of combined effort and cooperation and 
the enactment by the several States of similar requii'ements. It 
implies also an adequate enforcement of these requirements. The 
question of State morbidity reports is one of the most difficult prob- 



38 



lems to be solved by the State authorities. A mimber of States have 
been endeavoring earnestly to solve the problem within their respec- 
tive jurisdictions. Considerable progress has been made in several 
instances. The question is an important one, and is bound to re- 
ceive much consideration during the next decade. Tlie State health 
authorities in conference with the Public Health Service had the 
matter under consideration for some time and in June^ 1913, approved 
a model State law for morbidity reports. (See appendix pp. 71-74.) 
The model law makes the following-named diseases notifiable: 

Group I. — Infectious Diseases. 

Actinomycosis. 
Anthrax. 
Chicken-pox. 

Cholera, Asiatic (also cholera nostras when 
Asiatic cholera is present or its impor- 
tation threatened). 
Continued fever lasting seven days. 
Dengue. 
Diphtheria. 
Dysentery : 

(a) Amebic. 

(6) BaciUary. 
Favus. 

German measles. 
Glanders. 

Hookworm disease. 
Leprosy. 
Malaria. 
Measles. 
Meningitis: 

(a) Epidemic cerebrospinal. 

(6) Tuberculous. 
Mumps. 
Ophthalmia neonatorum (conjunctivitis 

of newborn infants). 
Paragonimiasis (endemic hem^optysis). 
Paratyphoid fever. 
Plague. 

Pneumonia (acute). 
Poliomyelitis (acute infectious). 
Rabies. 

Rocky Mountain spotted (or tick) fever. 
Scarlet fever. 
Septic sore thi'oat. 
Smallpox. 
Tetanus. 
Trachoma. 

The provisions of the model law slightly amended have already 
been adopted by the State of Kansas through regulations promul- 
gated December 1.3, 1913. As opportunity affords other States will 
undoubtedly take similar action. 



Group I. — Infectious Diseases — 
Continued. 

Trichinosis. 

Tuberculosis (all forms, the organ or part 
affected in each case to be specified). 
Typhoid fever. 
Typhus fever. 
Whooping cough. 
Yellow fever. 

Group II. — Occupational Diseases 
AND Injuries. 

Arsenic poisoning. 

Brass poisoning. 

Carbon monoxide poisoning. 

Lead poisoning. 

Mercury poisoning. 

Natm-al gas poisoning. 

Phosphorous poisoning. 

Wood alcohol poisoning. 

Naphtha poisoning. 

Bisulphide of carbon poisoning. 

Dinitrobenzine poisoning. 

Caisson disease (compressed-air illness). 

Any other disease or disability contracted 

as a result of the nature of the person's 

employment. 

Group III. — Venereal Diseases. 

Gonococcus infection. 
Syphilis. 

Group IV. — Diseases op Unknown 
Origin, 

Pellagra. 
Cancer. 



39 

The Results of Notification in Certain States and Cities. 

The completeness of the reports of the notifiable diseases in States 
and cities in which there is registration of deaths may be estimated 
with some degree of accuracy by comparing the number of cases 
reported with the number of deaths registered as due to the same 
cause. In doing this, however, it must be borne in mind that we do 
not know the fatality rates of many diseases, for up to the present 
time there have seldom been satisfactory morbidity records of suf- 
ficiently broad appUcation to permit of the determmation of such 
rates, and it must also be remembered that the f ataHty rates of many 
diseases vary in different epidemicg, and from year to year, and with 
the seasons and geographic location. 

To show the possibilities of notification and the results being 
obtained in certain diseases in those States and cities in which noti- 
fication has been developed to a degree approaching most closely 
one that is satisfactory, the following tables are presented. The 
diseases selected are diphtheria, measles, and typhoid fever. To 
this list others might be added. In the diphtheria table only those 
States and cities are included in which 10 or more cases v/ere reported 
for each death registered; in the measles table only those States and 
cities in which at least 50 cases were reported for each death regis- 
tered; and in the typhoid fever table only those in wliich 7 or more 
cases were reported for each death registered. One of the most 
interesting features of these tables, and one to which the reader's 
attention is invited, is the relatively large num-ber of cases reported 
in some cities and States for each death. The relatively small num- 
ber of fatal cases suggests the existence of fatahty rates much lower 
than those commonly beheved to prevail. 

The material for these tables was taken from the Public Health 
Reports,^ The data was originally obtained by the Surgeon General 
of the Public Health Service from the health departments of the 
several States and cities. The deaths given in the 1912 mortality 
statistics of the Bureau of the Census, which are now available, difl'er 
slightly in number in most instance from those used, but the differences 
are p.ot enough to affect appreciably the ratios of cases to deaths. 

To explain the wide differences in fatality rates in the several 
cities and States one should bear in mmd the possibility that the 
virulence of the diseases may at times vary and that the skill and 
facihties of practicing physicians for diagnosing certain affections 
may differ in the several locahties. 

1 Public Health Reports, Jan. 16, 1914, and Apr. 3, 1914. 



40 



DIPHTHERIA. 



Table 4. — Cases notified, case rates jper 1,000 population, number of cases notified for 
each fatality {death) registered, and fatality rates per 100 cases, in States and cities having 
10 or more cases notified for each death registered, 1912. 



States and cities. 



STATES. 

Connecticut 

District of Columbia , 

Massachusetts , 

Montana 

New York , 

Utah 

Virginia 

CITIES. 

Boston, Mass 

Cleveland, Ohio 

NewYork N. Y , 

St. Louis, Mo 

Cincuuiati, Ohio 

Los Angeles, Cal 

Newark , N . J 

New Orleans, La 

San Francisco, Cal 

Washington, D. C 

Denver, Colo 

Indianapolis, Ind 

Providence, K. I 

Rochester, N. Y 

St. Paul, Minn 

Seattle, Wash 

Albany, N.Y 

Birmingham, Ala 

Cambridge, Mass 

Columbus, Ohio 

Dayton, Ohio 

Grand Rapids, Mich 

Nashville, Term 

Richmond , Va 

Salt Lake City, Utah 

Spokane, Wash 

Syracuse, N. Y 

Worcester, Mass 

England and Wales (1911) 
London (1911) 



Cases. 



1,941 
393 

5,433 

139 

18,141 

328 

2,875 



1,539 

2,605 

13, 533 

2,548 

638 

433 

1,098 

1,072 

326 

393 

377 

633 

848 

495 

392 

224 

328 

220 

264 

415 

582 

100 

91 

206 

159 

66 

422 

411 

47,747 
7,404 



Fatal 

cases 

(deaths). 



191 
15 

473 

12 

1,641 

24 

92 



102 

166 

1,125 

170 

60 

25 

91 

58 

28 

15 

12 

35 

75 

16 

23 

11 

29 

14 

26 

39 

43 

10 

7 

8 

3 

5 

24 

26 



Case rate 

per 1,000 

population. 



1.758 
1.146 
1.555 

.342 
1.904 

.833 
1.363 



2.164 
4.363 
2.672 
3.578 
1.646 
1.121 
2.973 
3.056 

.752 
1.146 
1.637 
2.563 
3.605 
2.148 
1.472 

.807 
3.224 
1.464 
2.450 
2.141 
4.835 

.846 

.806 
1.567 
1.571 

. 545 
2.938 
2.701 

1.32 
1.64 



Fatality 
rate per 
100 cases. 



9.84 
3.82 
8.70 
8.63 
9.04 
7.31 
3.20 



6.62 
6.37 
8.31 
6.67 
9.40 
5.77 
8.28 
5.41 
8.58 
3.82 
3.18 
5.52 
8.84 
3.23 
5.86 
4.91 
8.84 
6.36 
9.84 
9.39 
7.38 
10.00 
7.69 
3.88 
1.88 
7.57 
5.68 
6.32 

10.26 
8.45 



Number 
of cases 
notified 
for each 
fatahty. 



15 
16 
12 
15 
11 
17 
12 
18 
12 
26 
31 
18 
11 
31 
17 
20 
11 
16 
10 
11 
14 
10 
13 
26 
53 
13 
18 
16 

9.75 
11.83 



MEASLES. 



Table 5. — Cases notified, case rates per 1,000 jwpidation, number of cases notified for 
each fatality {death) registered, and fatality rates per 100 cases, in States and cities having 
50 or more cases notified for each death registered, 1912. 



States and cities. 


Cases. 


Fatal 

cases 

(deaths). 


Case rate 

per 1,000 

population. 


Fatality 
rate per 
100 cases. 


Number 
of cases 
notified 
for each 
fatality. 


STATES. 


6,537 

1,638 
10,392 

1,675 
22, 423 
65,299 

3,117 


116 

7 

189 

20 

286 

1,049 

11 


5.630 
4. 778 
1.7S5 
2.233 
6.421 
6.854 
7.892 


1.77 
.42 
1.81 
1.20 
1.27 
1.60 
.35 


56 


District of Columbia 


234 




55 




84 


Massachusetts 


78 


New York 


62 


Utah 


283 



41 

Table 5 — Cases notified, case rates per 1,000 population, number of cases notified for 
each fatality {death) registered, and fatality rates per 100 cases, in States and cities having 
50 or more cases notified for each death registered, 1912 — Continued. 



states and cities. 



Cases. 



Fatal 

cases 

(deaths) . 



Case rate 

per 1,000 

population. 



Fatality 
rate per 
100 cases. 



Number 
of cases 
notified 
for each 
fatality. 



CITIES 

Boston, Mass 

Chicago, 111 

Cleveland, Ohio 

New York N. Y 

St. Louis, Mo 

Cincinnati, Ohio 

Los Angeies, Cal 

Milwaukee, W is 

New Orleans, La 

San Francisco, Cal 

Denver, Colo 

Indianapolis, Ind 

Rochester, N. Y 

St. Paul, Minn 

Albany, N. Y 

Birmingham, Ala 

Cambridge, Mass 

Dayton, Ohio 

Hartford, Conn 

Richmond, Va 

Salt Lake City, Utah... 

Spokane, Wash 

Syracuse, N. Y 

Toledo. Ohio 



5,666 

6,784 

2,230 

39,018 

6,549 

2,715 

253 

2,316 

324 

3,451 

72 

3,556 

2,002 

282 

437 

868 

1,015 

643 

663 

851 

1,074 

1,133 

605 

1,350 



111 


7.967 


119 


2.956 


34 


3.735 


671 


7.704 


73 


9.197 


34 


7.005 


1 


.655 


25 


5.785 


2 


.923 


47 


7.961 


1 


.313 


12 


14. 400 


28 


8.694 


1 


1.058 


2 


4.295 


9 


5.777 


10 


9.421 


7 


5.342 


12 


6.425 


1 


6.473 


2 


10.611 


6 


9.364 


7 


4.213 


27 


7. 635 



1.95 

1.75 

1.52 

1.72 

1.11 

1.25 

.39 

1.07 

.61 

1.36 

1.39 

.33 

1.39 

.35 

.45 

1.03 

.98 

1.08 

1.81 

.12 

.18 

.53 

1.15 

2.00 



253 
93 

162 
73 

72 
296 

71 
282 
218 

96 
101 

92 

55 
851 
537 
188 

86 

50 



TYPHOID FEVER. 



Table 6. — Cases notified, case rates per 1,000 population, number of cases notified for 
each fatality (death) registered, and fatality rates per 100 cases, in States and cities having 
7 or more cases notified for each death registered, 1912. 



states and cities. 



STATES. 

Connecticut 

District of Columbia 

Maryland 

Massachusetts 

Utah 

Virginia 

CITIES. 

Boston, Mass 

Cleveland, Ohio 

Philadelphia, Pa 

Newark, N. J 

Denver, Colo 

Providence, R.I 

Seattle, Wash 

Birmingham, Ala 

Bridgeport, Conn 

Cambridge, Mass 

Grand Rapids, Mich 

Hartford, Conn 

Lowell, Mass 

Richmond, Va. . .: 

Salt Lake City, Utah 

Worcester, Mass 

England and Wales (1911) 
London (1911) 



Cases. 



924 

585 

1,795 

2,088 

549 

4,330 



460 

271 

1,514 

193 

498 

206 

149 

490 

68 

55 

316 

76 

86 

208 

163 

70 

13, 730 
1,024 



Fatal 

cases 

(deaths). 



128 
78 

229 

269 
57 

260 



57 
38 
200 
26 
30 
24 
20 
56 

8 

5 
40 

4 
10 
22 
17 

5 

2,416 
145 



Case rate 

per 1,000 

population. 



0.795 
1.706 
2.387 
.597 
1.390 
2.054 



.647 
.454 
.942 
.523 

2.163 
.876 
.537 

3.261 
.532 
.511 

2. 674 
.737 
.791 

1. 582 

1.611 
.460 

.38 
.23 



Fatality 
rate per 
100 cases. 



13.85 
13.33 
12.75 

12.88 
10.38 
6.00 



12.39 
14.02 
13.21 
13.48 

6.02 
11.65 
13.42 
11.43 
13.80 

9.09 
12.66 

5.26 
11.63 
10.58 
10.43 

7.14 

17.62 
14.16 



Number 
of cases 
notified 
for each 
fatality. 



7.2 
7.5 
7.8 
7.8 
9.6 
16.6 



8.1 
7.1 
7.5 
7.4 

16.6 
8.6 
7.4 
8.7 
7.2 

11.0 
7.9 

19.0 
8.6 
9.5 
9.6 

14.0 

5.68 

7.06 



42 



As the result of Dr. Baker's work Michigan has records of the prev- 
alence of a number of communicable diseases from the early eighties. 
These records show that durmg the 15 years, 1882 to 1896, inclusive, 
there were in Michigan 1,320 reported cases of smallpox, mth 314 
deaths, and a fatality rate for the period of 23.8 per cent. During the 
succeeding 14 years, 1897 to 1910, inclusive, the State of Michigan had 
38,243 reported cases, with 361 deaths, and a fatality rate for the 
period of 0.94 per cent. During the 10 years, 1884 to 1893, inclusive, 
Michigan had an annual average of 3,909 reported cases of diphtheria, 
with an average of 913 deaths, and a fatality rate of 23.4 per cent. 
During the 17 years, 1894 to 1910, inclusive, the average annual 







1885 








1890 








1895 








1900 








1905 








1910 


































































































































Q 






























































'8 
















































V 


— / 


V— 
























































NJ 


/ 




\ 






































































7 














































/ 
























































A 






/ 
















6 






































/ 
























5 






















<» 


s 


/ 


^ 


\ 






__^ 


/ 








' 




































/ 


s 


/ 










































.— ■ 


"^ 




K 


\ 


/ 




— - 


f 








































4 






























































3 
























































































































































































Z 

















































































































































































































































u 




_ 


— 



Chart 10.- 



-Diphtheria— Number of cases notifled per annum for each death registered — Michigan- 
1884 to 1910. 



number of reported cases was 3,133, the average number of deaths 
529, giving a fatality rate of 16.9 per cent. During the 27 yearsy 
1884 to 1910, ]\iichigan had an average of 4,288 reported cases of 
scarlet fever, with' an average of 277 deaths, and a fatality rate of 5.3 per 
cent. The ]\lichigan records for measles go back only as far as 1890, 
and during the 21 years, 1890 to 1910, inclusive, the average number 
of cases reported annually was 10,995, with an average number of 
deaths of 148, giving a fatality rate based upon reported cases and 
deaths of 1.3 per cent. 

Source of Statistical Data. 

The manner of collecting the data from which morbidity statistics 
are compiled is closely allied to the registration method used for 
births. The data consist of the reports of cases of disease made usually 



by physicians and in some instances by the heads of families and house- 
holds. The original observers then, upon whom morbidity statistics 
depend chiefly for their completeness, are the practicing physicians. 
This is necessarily so, for neither the health department nor any 
other branch of government can keep in such close touch %vith the 
hves of the people as to be in a position to know of the occurrence of 
disease. The physician is the one, who because of the very nature of 
his woi'k and his relation to the community, is best able to have this 
information and furnish it. He comes in contact with the sick to a 
degree others do not. The health officer can not know of the 







1385 








1890 








1895 








1900 








1905 








I9!0 


































































































































jp 








i 


^M. 






V 


















































A 


\ 


/ 




\ 




\ 


























































\ 


/ 
















































15 












^ 
































1 








































J 


s 








I 










i 








































f 


\ 




/ 




N 


«=^ 


\ 






/ 


1 










































N, 


r 








\ 






\ 


1 














i 






































\ 






j 


1 




















































\ 


\ 




1 


1 


















— 


































\ 


"—=( 




1 






















































1 




























































' 


























































\ 


k' 


\ 


K 








































































(10 
























































































































































































































































































































_ 
















_ 












____ 














Lj 




_j 






^ 


■^ 



Chart 11. 



-DipMlieria— Fatality rate (number of deaths registered per amiura per 100 notified cases)— 
Michigan— 1884 to 1910. 



presence of disease except as it is reported to him by physicians. 
Experience has shown that there may be hundreds of cases of a 
dangerous infection in a city and the health officer not know of its 
presence in the absence of notification. 

Unfortunately many practicing physicians have httle knowledge of 
the methods of health administration and in common with people in 
general frequently expect the health department in some mysterious 
manner to control disease without placing upon them the burden and 
privilege of cooperating by the notification of the occurrence of cases. 
The practicing physician, whether he recognizes it or not, or is so 
recognized by the community, is essentially an adjunct of the health 
department, for unless he performs his part the health department is 
in large measure helpless. 



44 

Among practicing physicians, at least in the United States, there 
has at times been the feehng that the knowledge of a disease in a 
patient is privileged information which they should not be called upon 
to impart. In communities where the laws require the notifica- 
tion of the disease this feeling has no legal basis and the 
physician who does not make report is not a law-abiding citizen. But 
aside from the legal aspects of the matter there would seem to be 
httle justification for such a course. Every physician has a number 
of individuals or f amihes who look to him, and properly so, not only 
for treatment, but also for such reasonable protection from disease as 
he is able to give. The failure to report the occurrence of a case of 
communicable disease in one patient may lead to its spread to others 
among his clientele whose rights he has ignored. He therefore 
violates the intent and spirit of the ethical principle of the protection 
of patients among whom must be considered the well together with the 
sick. The notification of disease is in the interests and for the 
protection of the community, and as his patients are usually members 
of the community their interests are ignored and because of the anti- 
social whim or supposed convenience of the individual affected 
with a notifiable disease they are deprived of the protection they have 
a right to expect. It would seem that the physician who fails to 
report his cases of preventable diseases required to be notified may 
properly be considered as actively obstructing public health adminis- 
tration. 

Related in thought is the following quotation from an address by 
Prof. Victor C. Vaughan.^ 

However, no medical man treats any infectious disease without, at the same timo, 
rendering a service to the public. He takes care of his case of diphtheria, or scarlet 
fever, or measles, and at the same time he renders a larger service to the public in 
preventing the spread of infection. * * * 

In the future the training of the medical man must be developed largely with a 
view to his broader relations to the public. His proper function must be to prevent, 
rather than cure disease. The physician's duties are to become more and more largely 
official in the sense that his services are to be rendered to the community, and not 
exclusively to the individual. 

The health department laboratory may be, and in many places 
is, an important factor in giving information of the occurrence of 
cases and prevalence of certain diseases. By having a diagnostic 
laboratory with a trained personnel at the service of the practicing 
physician the health department becomes not only a consultant 
performing gratuitous service for the physician but at the same time 
secures early and accurate information of many cases which other- 
mse might not be properly diagnosed and therefore not reported. 
A record of every positive diagnosis made by the laboratory should 
be sent to the epidemiological bureau or other division of the health 

1 Pennsylvania Medical Journal, November, 1913. 



45 

department responsible for the control of disease and should for 
purposes of morbidity records constitute notification of the case when 
accompanied by such necessary information as the name, age, sex, 
and address of the patient. There would seem to be no good reason 
why the services of the health department should not be at the 
disposal of the community for the diagnosis of all diseases. 

Nature of Information Secured by Morbidity Notification. 

It is the practice for health departments to furnish to physicians 
notification blanks upon which the reports are to be made. In some 
instances these are in the form of post cards, wliich have proper spaces 
indicated for notation of the requii-ed information. These cards re- 
quire the physician to affix a stamp before mailing them to the health 
department. A far better practice is that employed by many States 
and cities of supplying physicians with postal-card forms which do 
not require additional postage before mailing. 

The information relating to the reported cases which physicians are 
required to give varies in the several States. It has usually been cus- 
tomary to require the physician, in making his report, to include all 
the data regarding the case desired by the health department. In the 
majority of instances no further data regarding these cases are secured 
by the health ofiicials. While it may be impracticable in most in- 
stances to change this practice at the present time, it must be recog- 
nized that a local health department should prefer to collect its data 
regarding each case itself, and should not be wilhng to depend upon 
the physician's report for its epidemiologic information. Logically, 
the only information which the physician should be depended upon to 
give in his report is the occurrence of a case, or a suspected case, of a 
given disease in such and such a person at such and such an address. 
He might properly be required to add to this such data as are matters of 
record or easily verified, such as the age, color, and sex of the patient, 
and simitar information. The local health department, however, should 
be reluctant to depend upon the diagnosis of the practicing phy- 
sician, unless the diagnosis has been verified by a trained diagnos- 
tician in the service of the department itself. This has been the 
practice during recent outbreaks of such diseases as yellow fever and 
plague. It is also the practice in certain other instances. It must 
necessarily become the practice whenever a determined effort is to 
be made in the control of any preventable disease. 

The Standard Notification Blank. 

The standard notification blank (see appendix, p. 74) approved by 
the State and Territorial health authorities of the United States in 
conference with the Pubhc Health Service at their tenth annual 
conference in June, 1913, calls for the following information: 

1. Date. 

2. Name of disease or suspected disease. 



46 

3. Patient's name, age, sex, color, and address. (This is largely for purposes of iden- 

tification and location.) 

4. Patient's occupation. (This serves to show both the possible origin of the disease 

and the probability that othera have been or may be exposed.) 

5. School attended by or place of employment of patient. (Serves same purpose as 

the preceding.) 

6. Number of persons in the household, number of adults and number of children. 

(To indicate the nature of the household and the probable danger of the spread 
of the disease.) 

7. The physician's opinion of the probable source of infection or origin of the disease. 

(This gives important information and frequently reveals unreported cases. It 
is of particular value in occupational diseases.) 

8. If the disease is smallpox, the type (whether the mild or virulent strain) and the 

number of times the patient has been successfully vaccinated, and the approxi- 
mate dates. (This gives the vaccination status and history.) 

9. If the disease is typhoid fever, scarlet fever, diphtheria, or septic sore throat, 

whether the i^atient had been or whether any member of the household is en- 
gaged in the production or handling of milk. (These diseases being frequently 
spread through milk, this information is important to indicate measm'es to i^re- 
vent further spread.) 
10. Address and signature of the physician making the report. 

These reports are to be made on postal cards fiirnislied for the 
purpose and mailed immediately to the local health department, so 
that proper measures can be taken to prevent the spread of the 
disease or to find the focns or source from which the case originated, 
that the occurrence of additional cases may be prevented. These 
reports are then to be forwarded to the State department of health, 
but before being forwarded the local health department is to note 
thereon : 

1. Whether the case was in^^estigated by the local health department. 

2. V/hether the natm-e of the disease was verified. 

3. What measures were taken by the local health department to prevent the spread 

of the disease or the occurrence of additional cases from the same origin. 

The standard notification blank has been adopted in two States. 

Sources of Error in Morbidity Statistics. 

The errors in morbidity statistics are due principally to incomplete 
notification — that is, to the failure of physicians to report all cases of 
the notifiable diseases. More cases of disease usually occur than are 
reported. This can never be entirely overcome, for many diseases 
vary in severity under different conditions, and some cases are so 
mild that their true nature is net recognized, and frequently they 
do not come to the attention of physicians. 

The cases notified are usually correctly diagnosed, for physicians 
do not generally report cases until they are practically sure of the 
diagnosis, as the case remains an evidence of faulty diagnosis if a 
mistake is made. Then, too, physicians naturally wish to report only 



47 

those cases required and to know whetlier a given case is one of 
these he must first be reasonably sure of his diagnosis. 

The errors in morbidity statistics are therefore chiefly tliose of 
incompleteness. In this they resemble birth statistics, although the 
degi'ee of incompleteness, due to the difference in the nature of the 
two, is usually greater in morbidity statistics. 

They differ from mortality statistics, in which the principal source 
of error is incorrect statements of cause of death. Due to the control 
possible over the disposal of bodies of the dead, it is not difficult iu 
most communities to obtain practically complete registration of 
deaths. It is, however, exceedingly difficult to secure correct state- 
ments of the causes of death. The physician feels compelled to give 
a diagnosis in each death certificate and usually does so even when 
he is uncertain of the nature of the malady, realizing probably that 
the body will be buried and that there will be nothing to show the 
error if one is made. 

The tendency is then in morbidity reports for the diagnoses to be 
correctly given, but not all cases reported, while in the registration 
of deaths the tendency is for the recording of practically all deaths 
but the fihng of many incorrect statements of the causes of death. 

Uses of Morbidity Reports and Statistics. 

In health administration, morbidity reports^ — that is, reports of 
cases of sickness — serve several purposes, which may be briefly stated 
to be as follows: 

1. In the communicable diseases morbidity reports show Ibhe 
occurrence of cases which constitute foci from which the disease may 
spread to others, as in scarlet fever, typhoid fever, tuberculosis, or 
yellov/ fever, and make it possible to take proper precautions to pro- 
tect the family of the patient, his associates, or the community at 
large. 

2. In some diseases morbidity reports make it possible to see that 
the sick receive proper treatment, as in ophthalmia neonatorum, 
diphtheria, and, in certain cities, tuberculosis. The reporting of 
cases of ophthalmia in the nev\^born makes it possible to save the sight 
of some mf ants who v/ould otherwise not receive adequate treatment 
until after much damage had been done. In diphtheria the health 
department can be of service in furnishing antitoxm. Some cities 
furnish hospital or other relief to consumptives who would other'svise 
be without proper treatment. 

3. In diseases that are not communicable, such as those due to 
occupation or environment, reported cases show the location of con- 
ditions v/hich are causing illness or injury. This makes it possible 
to remedy the faulty conditions, so that others may not be similarly 
injured. 



48 

4. In certain diseases, of which the cause or means of spread is 
unknown, morbidity reports show their geographic distribution and 
varying prevalence and the conditions under which cases occur. 
This information has great potential value in attempts to ascertain 
their causes and means of spread. 

5. Reports of the occurrence of disease are necessary to show the 
need of certain sanitary measures or works and to control and check 
the efficiency of such measures or w^orks when put into operation. 
In pulmonary tuberculosis such reports show the number of consump- 
tives in the community and the need of sanatoria. In malaria they 
show the prevalence of the disease, the need for drainage and other 
antimosquito work, the efficiency of such work when in operation, 
and when a change in the prophylactic measures or additional ones are 
necessary. In typhoid fever they show faults in the water supply or 
in the control of the production and distribution of milk or in the dis- 
posal of excreta m special localities. 

6. Morbidity reports when recorded over a period of time and 
properly compiled become a record of the past occurrence of disease. 
They show the relative prevalence of disease from year to year and 
under varying conditions. They show the effect of the introduction 
of public-health measures and of sanitary works. They give a his- 
tory of disease not obtainable m their absence. 

Morbidity Rates. 

" Crude morbidity rates.' — Morbidity rates may be expressed as the 
number of cases of a given disease occurring during a year per 1,000 
of the total population, or the rate may be expressed as the number 
of cases per 10,000 or per 100,000 population. Giving the rate per 
1,000 population has the advantage of employing the same popula- 
tion unit as that used for expressing birth, marriage, and death rates. 
It has, however, what has been considered by some a disadvantage, 
namely that the rates will more frequently be fractions where the 
1,000 unit of population is taken as the basis. For this reason 10,000 
and 100,000 population units have often been used. The medical 
officer of the local government board of England and Wales uses the 
1,000 unit in stating morbidity rates. 

Specific morbidity rates.- — Diseases limited entirely or principally to 
certain ages or to certain classes of the population should be expressed 
also in rates of the number of cases per 1,000 persons in the population 
of that age or class. Diseases limited to childhood should be ex- 
pressed as rates per 1,000 children; diseases limited to women should 
be expressed as rates per 1,000 women. Occupational disease rates 
should be expressed in terms of the number of cases per 1,000 persons 
employed. 



49 

Specific morbidity rates showing the incidence of disease by ag& 
groups, sex, occupation, and economic or social condition -will be 
possible -with the improved notification methods which are beino- 
gradually adopted. 

Fatality rates. — The fatality or case mortality rate of a disease is 
usually expressed in terms of the number of deaths per 100 cases; 
that is, as the percentage of cases which terminate fatally. In cal- 
culating fatality rates it is to be borne in mind that among cases 
reported during one week, month, or year, all or part of the fatal 
terminations may occur during a succeeding week, month, or year. 

Hospital statistics and siclcness insurance records. — In a number of 
foreign countries much valuable information regarding sickness 
rates, aside from that of the commonly notifiable diseases, is being 
secured from the workingmen's sickness insurance records. In some 
countries hospital statistics are compiled and furnish data of much 
value. Bolduan ^ has suggested a plan for compiling hospital mor- 
bidity statistics in this country. The method is especially applica- 
ble to the hospitals of a large city, but might be used for the hospitals 
of an entire State and is capable of being made nation wide in scope. 
The essential feature of the plan is the filling out of ''discharge certi- 
ficates," analogous to ordinary death certificates, on the discharge 
of each patient from a hospital. These discharge certificates are 
then sent to a central filing bureau, preferably the health department, 
and there classified and analyzed. For a copy of the proposed 
''discharge certificate" see appendix, page 75. 

The fund of valuable information which might be acquired by the 
use of the statistical method in the study of hospital experience and 
theproper treatment of hospital statistics has been most ably discussed 
by Frederick L. Hoffman in his work on "The Statistical Experience 
Data of the Johns Hopkins Hospital, Baltimore, Md., 1892-1911. "^ 

It is also especially desirable to have statistics of the insane and 
mentally defective. New Jersey has recently enacted a law requir- 
ing the notification of cases of mental deficiency and of epilepsy. 

Factors Influencing Morbidity Rates. 

The factors which influence morbidity rates and the prevalence of 
sickness are the manifold direct and indirect causes of disease. There 
are certain widely acting indirect factors which increase morbidity 
by lessening individual resistance. There are other factors which 
are specific for individual diseases. In malaria the direct cause is 
infectious anopheline mosquitoes, and the indirect cause swamps 

1 Bolduan, Charles F.; Hospital morbidity statistics; New York Medical Journal; Mar., 1913; p. 643. 

2 The Johns Hopkins Hospital Reports. Monographs, New Series No. IV. 

55256°— 14 4 



50 

and stagnant water in which the mosquitoes breed. The factors 
influencing typhoid fever rates are commonly the milk supply, the 
water supply, the manner of disposal of excreta, presence of flies, 
the extent to which houses are screened, personal and social habits, 
etc. In an industrial community the morbidity from occupational 
diseases and from diseases caused indirectly by the conditions attend- 
ing certain kinds of labor constitutes a factor the importance of 
which is beginning to be realized. A discussion of the factors influ- 
encing morbidity rates would require a treatise on epidemiology and 
hygiene. 

Notification of Occupational Diseases. 

Most civilized nations have during the last hundred years undergone 
an industrial revolution. It has been within this period that the large 
factory with its hundreds or thousands of workers has had its devel- 
opment and that many of our present industries and the majority 
of our industrial processes have been developed. So great has been 
this change in the industrial life of the people that there has been 
developed a new and unportant branch of hygiene and sanitation 
which is properly termed industrial hygiene. With this industrial 
development there have evolved new diseases and disabilities due 
to the nature of the individual's work or to the conditions incident 
to the work. Not only have new diseases in a sense been evolved, 
but a number of diseases previously rare have become much more 
common. Under existmg social conditions a large proportion of the 
people are engaged in some occupation, and the diseases of occu- 
pation merit the attention and consideration of the community. 

Due largely to the activities of the American Association for 
Labor Legislation the question of the control of occupational dis- 
eases has during the last few years been receiving much considera- 
tion. Naturally the first step in the control of the industrial dis- 
eases was the securing of a means by which the occurrence and 
prevalence of these diseases might be known to those whose duty it 
would be to control them. For this purpose, and largely because of 
the activities of the American Association for Labor Legislation and 
its secretary, John B.Andrews, a number of States have since 1911 
enacted laws requiring the notification of certain occupational dis- 
eases. Fourteen States have enacted laws on the subject. One 
State has enacted a law appointing a commission to draft regulations 
covering the notification and control of occupational diseases, and 
one State by regulation of the State board of health requires the 
notification of these diseases. Abstracts of the State requirements 
will be found in the appendix, pages 76-82. 

A number of State laws require cases of occupational diseases 
to be notified to the State health department, and others require the 



51 

notifications to be made to the State labor office. The results of notifi- 
cation have not been as j^et satisfactory. This may be due to the 
newness of the idea to the physician of considering whether a disease 
is occupational in origin. The medical schools have given httle 
attention to the subject. It is highly important to the practicing 
physician that he have a knowledge of the industries of his community 
and of the diseases and disabilities they are likely to cause. The 
proper and successful treatment of patients necessarily depends upon 
a knowledge of the direct or indirect cause of the individual's ailment, 
and in an industrial community this ^vill depend frequently upon a 
knowledge of occupational diseases. 

A number of States have enacted lav/s which should in a way be 
much more successful in bringing to light the occurrence of these 
diseases (Illinois, Missouri, Ohio, and Pennsylvania. See appendbc, 
pages 76, 78, and 79) . The plan referred to is that of requiring certam 
industries to have their employees examined physically by a competent 
physician at stated intervals to ascertain whether there exist in the 
employees any ailments or disabilities due to the nature of their 
occupation. The physicians making these examinations naturally 
become in time expert, if they are not so in the beginning, and the 
examination of the employees in this way will guarantee the finding 
of a large proportion of the cases of industrial diseases, and that in 
most instances in their earliest stages. If the occupational diseases 
are to be controlled, it is necessary that the occurrence of cases be 
ascertained in some way, for the occurrence of each case shows the 
existence of conditions which have produced disease in one employee 
and "wnll in all probabihty produce it in others. Each case notified 
shows a danger spot. 

MORTALITY STATISTICS. 

Mortality statistics are statistics of deaths. They are of interest 
primarily because of their relation to changes in population. Aside 
from the factor of emigration, mortalit}^ statistics show the losses in 
numbers being sustained by the population, just as birth records 
show the additions. Wliere migration is a factor having an appre- 
ciable effect upon population it hkewige merits statistical considera- 
tion, for it, too, represents population gains and losses. 

Mortality statistics have performed another important service in 
creating an interest in pubhc health administration and securing 
support for sanitary measures. They show the extent of the loss by 
death caused by diseases. In the absence of morbidity records they 
have also frequently been used as an index of the prevalence of certain 
infections. It has been possible to use mortality statistics for the 
latter purpose on the assumption that the fatahty rates of disease 



52 



are fairly constant, 
holme lias said: 



However, we should bear in mind what News- 



The registration of deatlis gives a very imperfect view of tlie prevalence of disease. 
* * * It is fallacious to assume any fixed ratio between sickness and mortality. 
Tlie fatality of a given infectious disease varies greatly in different outbreaks under 
varying conditions. The highest ratio of sickness is occasionally found associated 
with a favorable rate of mortality. 

This absence of fixed fatality rates is shown by the experience in 
the United States with smallpox, in which the ratio of deaths to cases 
hag varied from 1:1^000 to 1:3; measles, in which the ratio of 
deaths to cases has been from 1:800 to 1:5; typhus fever (Brill's 
disease), in which it hag varied from 1 : 5 to practically no fatahty; 
and typhoid fever, in which the ratio has varied from 1 : 24 to 1:5. 

Registration of Deaths in England and the United States. 

The history of the registration of deaths in England and the United 
States is coupled with that of marriages and births, and was referred 
to previously in connection with the registration of births. The 
accurate registration of deaths in England dates from 1837. In the 
United States dependable registration was first enforced in Massa- 
chusetts and New Jersey. Other States have had laws of various 
types, mostly inadequate. Only recently have any number of 
States secured anything like complete registration. The bringing 
about of accurate death registration in the United States is due largely 
to the efforts made by the Bureau of the Census, and especially to the 
untiring efforts of Dr. Cressy L. Wilbur, chief statistician. 

United States Registration Area for Deaths. 

The registration area for deaths established by the United States 
Bureau of the Census includes the States and cities in other States 
which effectively enforce satisfactory registration laws and in the 
opinion of the Dhector of the Census have at least 90 per cent of all 
deaths registered. This area was first established in 1880 and at that 
time included Massachusetts, New Jersey, and certain cities in other 
States. The States included for 1912 were: ^ 



California. 

Colorado. 

Connecticut. 

Indiana. 

Kentucky. 

Maine. 

Maryland. 

Massachusetts. 

Michigan. 



Minnesota. 

Missouri. 

Montana. 

New Hampshire. 

New Jersey. 

New York. 

North Carolina (municipal- 
ities of 1,000 population 
or over in 1900). 



Ohio. 

Pennsylvania. 

Rhode Island. 

Utah. 

Vermont. 

Washington. 

Wisconsin. 



I Virginia v\'as ndded for 1913. 



53 



The registration cities in nonregistration States were : 



Alabama: 


Kansas : 


South Carolina: 


Birmingham. 


Atchison. 


Charleston. 


Mobile. 


Coffeyville. 


Tennessee: 


Montgomery. 


Fort Scott. 


Knox\dlle. 


Delaware: 


Hutchinson. 


Memphis. 


Wilmington. 


Independence. 


Nashville. 


Florida: 


Kansas City. 


Texas: 


Jacksonville. 


Lawrence. 


El Paso. 


Key West. 


Leavenworth. 


Galveston. 


Georgia: 


Parsons. 


San Antonio 


Atlanta. 


Pittsburg. 


Virginia: 


Savannah. 


Topeka. 


Alexandria. 


Illinois: 


Wichita. 


Danville. 


Aurora. 


Louisiana: 


Lynchburg. 


Belleville. 


New Orleans. 


Norfolk. 


Chicago. 


Nebraska: 


Petersburg. 


Decatur. 


Lincoln. 


Richmond. 


Evanston. 


Omaha. 


Roanoke. 


Jacksonville. 


Oregon: 


West Virginia: 


Quincy. 


Portland. 


Wheeling. 


Springfield. 


Source of Data. 





The origmal information from which mortahty statistics are derived 
is obtained by the registration of deaths. This is commonly accom- 
plished by the use of a blank or schedule prepared for the purpose and 
in this country known as a death certificate. The model law for the 
registration of births and deaths provides that no body shall be 
interred or otherwise disposed of or removed or temporarily held pend- 
ing further disposition "more than 72 hours after death unless a permit 
for burial, removal, or other disposition thereof shall have been prop- 
erly issued by the local registrar of the registration district hi which 
the death occurred or the body was found. And no such burial or 
removal permit shall be issued by any registrar untU, wherever j^rac- 
ticable, a complete and satisfactory certificate of death has been filed 
with him * * *." This msures the making of a death certificate 
and its registration in each instance of death unless the body is sur- 
reptitiously and illegally disposed of. It therefore guarantees practi- 
cally complete registration. In the rural districts of some localities 
bodies are frequently interred in private burial grounds and on farms 
in some chosen spot on the premises. Under these conditions bodies 
would occasionally be buried without registration, due to ignorance of 
the law. To meet the needs in such case the model law suggests a 
clause requiring every person or firm selling a casket (at retail) to 
keep a record showing the name and address of the purchaser, the 
name of the deceased, and date and place of death, and on the first 
of each month to report to the State registrar the sales for the pre- 



54 

ceding month; also to inclose in each casket sold a notice calling 
attention to the requirements of the law and a blank certificate of 
death. These provisions do not apply when the person selling the 
casket is the undertaker in charge of the burial. 

The Standard Death Certificate. 

The standard death certificate in use throughout the registration 
area for deaths calls for the following information: 

Place of death. 

Name, sex, color, race, conjugal condition, age, date of birth, occupation, and birth- 
place of decedent, name and birthplace of father, maiden name and birth place of 
mother. 

Signature and address of informant giving preceding information. 

Date and time of death and a statement as to the duration of medical attendance 
on the decedent, the cause of death, and its dm-ation, are to be given by the attending 
physician, if any, last in attendance. 

When the decedent was a recent resident or died in a hospital or other institution, 
the length of residence at place of death is to be given and also the former or usual 
residence and the place where the disease or injury was contracted. 

The date and intended place of burial and the address of the undertaker are to be 
given over the undertaker's signature. 

The date when the certificate is filed is inserted by the registrar with his signature. 

The responsibility of seeing that a certificate is properly made out 
and filed with the registrar rests prunarily upon the undertaker, 
according to the provisions of the model law, which specifies as fol- 
lows : 

Sec. 9. That the iindertaker, or person acting as undertaker, shall file the certificate 
of death with the local registrar of the district in which the death occurred and obtain 
a burial or removal permit prior to any disposition of the body. He shall obtain 
the required personal and statistical particulars from the person best qualified to 
supply them, over the signature and address of liis informant. He shall then present 
the certificate to the attending physician, if any, or to the health officer or coroner, 
as directed by the local registrar, for the medical certificate of the cause of death and 
other particulars necessary to complete the record, as specified in sections 7 and 8. 
And he shall then state the facts required relative to the date and place of burial or 
removal, over his signature and with his address, and present the completed certificate 
to the local registrar in order to obtain a permit for burial, removal, or other disposition 
of the body. The undertaker shall deliver the burial permit to the person in charge 
of the place of burial, before intemng or otherwise disposing of the body; or shall 
attach the removal permit to the box containing the corpse, when shipped by any 
transportation company; said permit to accompany the corpse to its destination, 

where, if within the State of , it shall be delivered to the person in charge of 

the place of burial. 

Sources of Error. 

In the use of mortality statistics as well as other statistics erroneous 
and unwarranted conclusions are sometimes arrived at by attempting 
to compare incomparable data. Mortality rates secured by lax 
enforcement or faulty methods of registration can not properly be 



55 

compared with those based upon complete registration. Nor can 
the rates of communities with populations of different sex and age 
composition be compared unless proper allowances are made and 
the rates expressed in terms of the same population. For example, 
it is improper to compare the mortality rate of an aggregation 
of young men picked for physical soundness, such as an army or 
navy, with the crude or general mortality rate of a civilian popula- 
tion. The nearest means of making comparison would be to compare 
the rate of the picked body of men with the rate among men of 
the same age groups in the civil population. But even this would 
be faulty, for the one group would consist of men specially picked 
for physical fitness while the other group would include the fit and 
the imfit, the strong and the weak. Nor is it possible to compare 
the mortality rate of any special population group with the rate of 
the population from which it has been derived by mtentional or 
other process of selection unless the differences in population com- 
position are considered. Thus it would give little information of 
value regarding the effect of locality and environment upon the 
duration of life to compare the mortality rate of New York City 
or the registration area of the United States with that of the Canal 
Zone without taking into account any differences which may have 
been produced in the age and sex composition of the two populations 
by the selective process naturally operating in the case of the Canal 
Zone, For the same reason there is little to be gained by comparuig 
the mortality rate of any American city or State with that of the 
civil employees of the Philippine Islaads or any other similar group 
unless based upon an analysis of age and sex composition of the 
populations. 

Another possible source of error in mortality statistics which 
requires to be considered is the original data contained in the death 
certificates from which the statistics are compiled. The personal and 
statistical particulars usually furnished by some member of the 
family are undoubtedly in most mstances accurate with the exception 
of the statement of occupation of the decedent, which offers unusual 
difficulties, due to the indefiniteness of many of the terms commonly 
used m so far as showing the exact kind of work is concerned. This 
is due in some measure to the fact that the nomenclature in common 
use has not progressed apace with the rather rapid development 
of new industries and industrial processes and methods. Whereas 
50 years ago the statement of occupation would have been in most 
cases comparatively simple and easily understood, to-day with 
changed industrial conditions the matter requires greater precision 
if useful statistical information is to result. 

Perhaps the most common error entermg into death registration, 
and therefore into mortality statistics, is m connection with the 



56 

statement of cause of death. Aside from the fact that in the 
instances in which it has been impossible for the attending physician 
to feel reasonably certain as to the nature of the terminal illness 
a cause of death is nevertheless usually stated in the certificate, 
and also the fact that at times the physician knowing the nature of 
the illness may, in the belief that he is shielding the family from 
odium or because of their whim, intentionally state an erroneous 
cause of death, there stiU remam the many unavoidable errors of 
mistaken diagnosis. Just how great a factor this last may be it is 
difficult to estimate. 

However, the findings of Dr. Richard C. Cabot ^ give at least 
a hint of its possible importance and the extent to which it may 
affect that part of mortality statistics relating to causes of death. 
In a study of 3,000 autopsies with regard to the relation of the 
actual cause of death as found post mortem to the clinical diagnosis 
Cabot found that the percentage of correct diagnoses in various 
diseases was as follows: 

Percentage of 

correct 

diagnosis. 

Diabetes melitus 95 

Typhoid 92 

Aortic regurgitation 84 

Cancer of colon 74 

Lobar pneumonia 74 

Chronic glomerulonephritis 74 

Cerebral tumor 72. 8 

Tuberculous meningitis 72 

Gastric cancer 72 

Mitral stenosis 69 

Brain hemorrhage 67 

Septic meningitis 64 ' 

Aortic stenosis 61 

Phthisis, active 59 

Miliary tuberculosis 52 

Chronic interstitial nephritis 50 

Thoracic aneurism 50 

Hepatic cirrhosis : 39 

Acute endocarditis 39 

Peptic ulcer 36 

Suppurative nephritis 35 

Renal tuberculosis 33. 3 

Broncho-pneumonia 33 

Vertebral tuberculosis 23 

Chronic myocarditis 22 

Hepatic abscess 20 

Acute pericarditis 20 

Acute nephritis 16 

1 Cabot, Richard C. Diagnostic pitfalls identified during a study of 3,000 autopsies. — Journal American 
Medical Association, Dec. 28, 1912, p. 2295. 



57 

The cases studied were hospital cases under conditions assumed 
to be favorable to correct diagnosis. It is quite safe to assume that 
in medical practice at large the percentages of correct diagnosis would 
be found lower than those found by Cabot. 

McLaughlin and Andrews ^ carried on an investigation in Manila 
into the nature of the diseases from which children were dying. They 
made post-mortem examinations of children in which,certain diseases 
had been given as the cause of death. The diseases selected were 
those appearing most frequently in death certificates. The reason 
for the investigation was to ascertain whether the death certificates 
showed the real causes of death in children in Manila and if npt what 
the actual causes of death were. 

Of 37 supposed cases of acute meningitis in children under 9 years 
of age the actual causes of death as found post-mortem were: 

Acute meningitis 2 

Pneumonia 2 

Empyema 1 

Beriberi 10 

Cholera. 18 

Undetermined (not meningitis) 3 

Enterocolitis 1 

Total 37 

Of 22 supposed cases of enteritis, dysentery, and gastroenteritis 
in children under 7 years of age the actual causes of death found 
post-mortem were: 

Cholera 15 

Beriberi 2 

Pneumonia 2 

Enterocolitis 3 

Total 22 

Of 40 cases in which the cause of death was given as "infantile 
convulsions" (all but 2 were infants under 1 year of age), the actual 
causes of death as found post-mortem were: 

Beriberi 31 

Cholera 4 

Pneumonia 1 

Enterocolitis 1 

Empyema 1 

Cerebral hemorrhage 1 

Undetermined 1 

Total 40 

' McLaughlin, Allan J., and Andrews, Vernon L. Studies on Infant Mortality, Philippine Journal of 
Science, Vol. V, No. 2, July, 1910, p. 149. 



58 

In 27 cases in which the causes of death given in the death certifi- 
cate were acute or chronic bronchitis or bronchopneumonia the actual 
causes were found to be : 

Beriberi 14 

Pneumonia - 6 

Meningitis 2 

Nephritis 2 

Chronic colitis 1 

Acute tonsillitis, pharyngitis, and bronchitis 1 

Undetermined 1 

Total 27 

In 50 cases (all in infants under 1 year of age except 1) certified 
as dying from ''infantile beriberi" the actual causes of death were 
found to be: 

Beriberi 40 

Cholera 3 

Bronchopneumonia 3 

Enterocolitis 1 

Undetermined 3 

Total 50 

A summary of the series was as follows : 



Assigned causes of death. 

Meningitis 37 

Enteritis 22 

Convulsions 40 

Beriberi 50 

Bronchitis 27 

Total 176 



Causes of death ascertained hy autopsy. 

Cholera 40 

Beriberi 97 

Pneumonia 14 

Enterocolitis 7 

Meningitis 4 

Nephritis 2 

Empyema 2 

Acute tonsillitis, pharyngitis, and 

bronchitis 1 

Cerebral hemorrhage 1 

Undetermined 8 

Total 176 

In the registration area of the United States very probably the 
causes given in death certificates of children correspond more nearly 
to the actual causes of death than they did in Manila. This, how- 
ever, should be ascertained by careful studies. Mortality statistics 
can not be more accurate than the death certificates from which they 
are compiled. 

For a further discussion of the possible scope of the inaccuracies 
entering into mortality statistics because of the faulty or incorrect 
statement of cause of death on death certificates the reader is referred 
to the Twelfth Annual Report of the Bureau of the Census giving mor- 
tality statistics for the year 1911, pages 36 to 38. 



59 

Uses of Death Registration. 

Death registration serves a number of highly important purposes. 
Its functions are legal, economic, and social. Death registration is 
useful in preventing and detecting crime through the restrictions 
placed upon the disposal of dead bodies. It serves as evidence in the 
inheritance of property and in the settlement of life insurance con- 
tracts and policies. It is only proper that the time, place, and cause 
of death of each indi^ddual should be made a permanent record for 
both sentimental and legal .reasons. 

Death registration makes it possible to show by mathematical 
computations and statistical methods the extent and rate of change 
in population produced by deaths; the average duration of life; and, 
to the extent that the certified causes of death have been correctly 
stated, the relative frequency with which the several causes produce 
death. Death statistics by comparison with birth statistics give 
useful information regarding population increase or decrease. 

Death Rates. 

Death rates may be expressed as the ratio of the total number of 
deaths, taken as a unit, to the population. For example: 1 in 60. 
The usual method, however, is to express these rates in terms of the 
number of deaths per 1,000 population, or in some instances per 10,000 
or even 100,000, or 1,000,000. 

Crude death rates. — The rate which shows the proportion of all deaths 
to the total population, and which is usually obtained by dividing 
the total number of deaths by the total population in thousands, is 
known as the crude death rate; also as the general or central death 
rate. To compute the crude death rate the total number of deaths 
during a year and the mean population for the year (estimated popu- 
lation as of the middle of the year, for the calendar year as of July 1) 
are taken. To illustrate: In a city having a total of 900 deaths dur- 
ing a calendar year, and an estimated population of 60,000 as of July 

1 of the year, the crude death rate would be 900 -^ ^ ' „„ =15 and 
-^ ' 1,000 

would be expressed as 15 per 1,000 population. 

Crude death rates are of value chiefly to show the numerical loss of 
the population by death. They also serve as a satisfactory basis for 
the comparison of the death rates of different communities having 
populations of similar composition as to age and sex. For populations 
of dissimilar composition they are not suitable as a basis of compari- 
son, for the death rates of women are usually lower than those of men 
and the death rates of the several age groups vary within wide limits, 
and the death rate, therefore, depends to a marked degree upon the 
relative numbers of males and females and the proportion of the popu- 
lation included in the various age groups. 



60: 

Death rates for short periods. — Death rates for short periods (for a 
week, month, or quarter) are expressed, in terms of annual rates; that 
is, what the annual rate would be provided deaths occurred through- 
out the year with the same frequency as during the week or month 
under consideration. Death rates for short periods are likely to have 
little significance, as quite accidental causes may affect them to a con- 
siderable degree. Taken for a number of years, however, they give 
useful information regarding seasonal variations. If in a city there 



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Chaet 12.— Births and deaths (exclusive of stillbirths) per 1,000 population per aimum— German 

Empire— 1SS6 to 1911. 

were 20 deaths during a given week and the mean population of the 
city for the year was 60,000, then the crude death rate for the week 
would be 

17.38. 

The mortahty for the week would, therefore, be at the rate of 17.38 
per 1,000 population per annum. 

Specific death rates. — Special or specific death rates are the rates 
.of specified or limited subgroups of the population. These subgroups 
may be obtained by dividing the population according to sex, age, race, 



61 

social condition, occupation, and so on. Specific death rates may be 
stated as the proportion of the number of deaths per annum in the 
subgroup per 1,000 of the mean annual number of the population in 
that subgroup. Sometimes specific death rates are given in terms of 
10,000, 100,000, Ox- 1,000,000 of the subgi'oup population. 

Among the most important of the specific rates are those relating 
to age groups. Their significance is shown by the following statement 
of rates for the registration States of the United States for the year 
1911: 

Death rate 
Age group. per 1,000. 

Under 1 year : 112. 9 

1 to 4 years 11. 8 

5 to 9 years 3. 1 

10 to 14 years : 2. 2 

15 to 19 years 3. 6 

20 to 24 years 5.2 

25 to 34 years 6. 4 

35 to 44 years 8. 9 

45 to 54 yearc 13. 6 

55 to 64 years 26. 2 

65 to 74 years 55. 2 

75 years and over 138. 9 

All ages 13. 9 

Specific race group rates are also important. In the registration 
area for deaths in 1911 the death rate for the wliite population was 
13.7 and that of the colored 23.7 per 1,000, while the rate of the two 
groups taken together was 14.2 per 1,000. 

The death rate differs also in the two sexes. In the registration 
area for deaths in 1911 the death rate for males was 14.7 and for 
females 13 per 1,000. 

Standardized death rates. — Due to the wide variation in the death 
rates at different ages it is impossible to satisfactorily compare the 
crude death rates of populations differing in composition as regards 
the relative number of individuals in the several age groups. The 
International Statistical Institute recommended (1895) that to facili- 
tate the comparison of death rates the population of Sweden as it 
existed in 1890 be used as a standard population for the statement of 
rates. Rates expressed in terms of a standard population are known 
as standardized or corrected rates. The method is as follows: Take 
the population for which it is deshed to state the standardized death 
rate and ascertain the specific death rates of its several age groups. 
Now take the corresponding age groups in 1,000,000 of the standard 
population and compute the number of deaths that would have 
occurred in each age group at the specific death rate found to exist 
in the population for which the standard death rate is being com- 
puted: add the number of deaths which it is thus found would have 
occurred in the age groups of the standard population. This gives 



62 



the standardized rate per 1,000,000. The standardized rate per 
1,000 is obtained by moving the decimal point three places to the 
left. 

The standardized death rate is the rate which would have occurred 
in the standard population if the death rates in its several age groups 
had been the same as those of the corresponding age groups of the 
population mider consideration. 

The registrar general of births, marriages, and deaths of England 
and Wales has for some years taken for a standard the population 
composition of England and Wales as shown by the 1901 census. 
The population of Sweden of 1890 was divided without distinction 
of sex into the five age groups: Under 12 months of age, over 12 





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Chart 13.— Birtlis and deaths (exclusive of stillbirths) per 1,000 population per aniram— France— 

1886 to 1011. 

months and under 20 years, 20 to 39 years of age inclusive, 40 to 59 
years of age inclusive, and 60 years of age and over. The population 
of England and Wales is classified separately by sexes in quinquennial 
age groups and furnishes a much more delicate and exact standard 
for measurement. The use of the Swedish population standardizes 
for age; the use of the English standardizes for both age and sex. In 
the United States a standard would be useful which would standard- 
ize for age, sex, and race (white and colored). 

Factors Affecting Death Rates. 

Death rates are affected not only by tbe statistical methods used 
in their preparation and by the age, sex, and race composition of the 
population, the social,^ marital, and economic status of the people, the 
nature and conditions of employment and the adaptability of a 
people to their environment, but also in limited areas by a number 
of other factors, such as the location of hospitals and institutions. 



Nonresidents — Hospitals and institutions. — Frequently a hospital 
or other mstitution will be located in one community while its pa- 
tients or inmates will come largely from other places. The extent to 
which this is true depends upon the nature or reputation of the hos- 
pital or institutioru The result may be that the local death rate will 
be affected to an appreciable extent by deaths of nonresidents in such 
institutions. In England and Wales an attempt has been made dur- 
ing the last two or tliree years to overcome this diJBEiculty by the 
allocation of all deaths in so far as possible to the locality of usual 











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Chaet 14.— Births and deaths (exclusive of stillbirths) per 1,000 popailation per annum— Massachusetts— 

1871 to 1911. 

residence. In eompilmg deaths for a registration district or area 
for the purpose of showing death rates, erroneous i>esults will be 
obtained if the deaths of nonresidents are excluded and no additions 
made for the deaths of residents which are contmuaUy occurring and 
being registered elsewhere. In the absenee of a dependable nie,ans 
of inclndrng the deaths of residents occurring in other districts it is, 
nnless under most exceptional circumstances, unsafe to exclnde the 
deaths of nonresidents. 

IHgratioQi. — Migration affects death rates by changmg the age, 
sex, or race composition of the population. Migi-ants are likely to 
consist more largely of males than of females, of young adults than 
of the extremes of life. The effect of migration depends upon whether 
the balance is one of emigration or immigration and the nature of the 
m.igrants lost or gained. 



64 



Birth rate. — Ignoring the question of migration, a population 
increases because of tlie excess of births over deaths, natural in- 
crease. In a stationary population the birth rate equals the death 
rate. As aU born must eventualy die the birth rate depends for its 
excess over the death rate upon the ever-increasing number of child- 
producing elements in the population and the resulting greater num- 
bers in the younger age groups. Other things being equal, a com- 
munity with a high birth rate wiU, because of the greater proportion 
of the population in the younger age groups, have a lower crude death 
rate than a community with a low birth rate. 

Marital condition.— M-Ovidliij in certain countries seems to be more 
dependent on marital conditions than on sex. This is shown by the 
following table taken from a paper entitled "Some Researches Con- 
cerning the Factors of Mortality, " by Lucien March (Journal of the 
Royal Statistical Society, London, March, 1912): 

Table 7. — Showing for the period 1886-1895, the number of deaths per 10,000 persons 
according to their marital status in France, Prussia, and Sweden. 





Males, aged^ 


Females, aged— 




20-39 


40-59 


60 and 
over. 


20-39 


40-59 


60 and 
over. 


France: 


77 
103 

2n 

71 
84 
201 

53 
83 
104 


153 
24(i 
293 

175 
231 
346 

114 
204 
190 


583 

794 

1,148 

582 

806 

1,091 

453 
090 
856 


80 

78 

145 

79 
59 
101 

66 
61 

98 


121 

166 
198 

128 
179 
172 

96 
120 
132 


456 




730 




930 


Prussia: 

Married 


497 


Single 


729 




805 


Sweden: 


364 


Single . . . . 


528 




698 







Table 8. — Death rates (exclusive of stillbirths) per 1,000 pojoulation in 

1886 and 1911.^ 


certain countries, 


Country or State. 


1886 


1911 




15.4 
29.7 
18.1 
19.5 
22.2 
22.5 
26.2 
31.7 
17.8 
28.7 
21.8 
10.5 
16.2 
26.7 
18.9 
29.6 
29.3 
16.6 
2 19.8 
16.2 
18.6 
8.9 


10.7 




21.9 




13.6 


England and Wales .^ 


14.6 




16.5 




19.6 




17.3 




25.1 




16.5 


Ita'y 


21.4 




14.5 




9.3 




13.2 




25.1 




15.1 




21.8 




23.2 




13.8 




14.2 




15.4 




15.3 




13.3 







1 Taken from the Seventy-fourth Aimual Report of the Registrar General of Births, Deaths, and Marriages 
in England and Wales, 1911, except the rates for Connecticut, Massachusetts, Michigan, and the United 
States. 

» Year 1880. 



65 



It will be noted in Table 8 that there has been a marked fall in the 
crude death rates throughout the civilized world. Louis I. Dublin/ 
statistician of the Metropolitan Life Insurance Co., has discussed the 
nature of this reduction in the death rate in the United States. He 
directs attention to the fact that the reduction has been entireh^ in 
the lower age groups, and that the death rates for the ages above 45 
in males and above 55 in females were higher in 1911 than in 1900. 
The following table illustrating the nature of the changes is taken 
from Dublin's paper: 

Table 9. — Comparison of mortality of males and females, by age groups; death rates per 

1,000 population. (Dublin.) 

[Registration States as constituted in 1900.1 





Males. 


Females. 


Age. 


1900 


1911 


Per cent 
increase 

or 
decrease. 


1900 


1911 


Per cent 
Increase 

or 
decrease. 


Under 5 


54.2 

4.7 

2.9 

4.9 

7.0 

8.3 

10.8 

15.8 

28.9 

59.6 

146.1 


39.8 

3.4 

2.4 

3.7 

5.3 

6.7 

10.4 

16.1 

30.9 

61.6 

147.4 


-26.57 
-27. 66 
-17. 24 
-24. 49 
-24. 29 
-19.28 
- 3.70 
+ 1.90 
+ 6.92 
+ 3.36 
+ .89 


45.8 

4.6 

3.1 

4.8 

6.7 

8.2 

9.8 

14.2 

25.8 

53.8 

139.5 


33.3 
3.1 
2.1 
3.3 

4.7 

6.0 

8.3 

12.9 

26.0 

55.1 

139.2 


27 29 


5-9 


32 61 


10-14 


32 26 


15-19 


31 25 


20-24 


29 85 


25-34 


26 83 


35-44 


15 31 




9 15 


55-64 


+ 78 


65-74 


+ 2.42 
— 0.22 


75 and over 






All ages 


17.6 


15.8 


-10.23 


16.5 


14.0 


— 15.15 







Similarly instructive is the following taken from a table prepared 
by Guilfoy^ showing the difference in the mortality rates for the 
various age groups in 1868 and in 1907 in the city of New York. 

Table 10. — Death rates per 1,000 persons at different age periods in New Yorlc City, with 
increase or decrease percentage from, all causes for the years 1868 and 1907. {Guilfoy.) 





Rates. 


Per cent, 
increase 




186S 


1907 


or 

decrease. 


Males: 

Under 5 years 


130.6 
10.1 
5.04 
6.14 
13.42 
16.21 
18.01 
20. 32 
26.36 
42.15 

103. 71 
32.12 


57.85 

4. .58 

2.68 

5.24 

7.62 

9.42 

12.50 

18.25 

31.84 

49.87 

107.1 

21. 13 


-56 


5-9 


-55 


10-14 


-47 


15-19 


-15 


20-24 


-43 


25-29 . . .. 


-42 


30-34 


-31 


35-44 


-10 


45-54 


+21 


55-64 


+ 13 


65 and over 


+ 3 


All ages 


-34 



1 Dublin, Louis I. "Possibilities of reducing mortality at the higher age gi-oups," Americal Journal of 
PubUc Health, Dec, 1913. 

2 Guilfoy, Wm. H., "At -what age periods and in what measure has the reduction in the mortality rate 
from tuberculosis manifested itself in the c.^ty of New York during the past forty years?" New York Med, 
Jour.;Nov. 28, 1908. 

55256°— 14 5 



66 

Table 10. — Death rates per 1,000 persons at different age periods in Neiv Yorlz City, with 
increase or decrease ■percentage from all causes for the years 1868 and 1907 (Guilfoy) — 
Continued. 





Rates. 


Per cent, 
increase 




1868 


1907 


or 

decrease. 


Femates: 


118.9 
9.08 
3.36 
5.74 
10.91 
12.84 
14.24 
15.83 
17.69 
29.37 
88.40 
26.52 

124.8 
9. GO 
4.19 
5.92 
12.03 
14.42 
16.13 
18.08 
22.10 
35.59 
94.84 
29.24 


49.57 
3.74 
2.75 
4.14 
5.45 
6.82 
8.85 
12.44 
19.67 
38.43 
97.30 
16.53 

53.74 

4.1G 

2.72 

4.65 

6.43 

8.11 

10.77 

15.54 

25.90 

44.06 

101. 7 

18.97 


-58 


5 9 


-59 


10 14 


-18 


15 19 


-28 


20 24 


-.:0 


25 29 


-47 


30 34 


-38 


35-44 


-21 


45 64 


+ 11 


55 64 


+31 




+ 10 




-38 


Both sexes: 


-57 


5 9 


-57 


10 14 


-35 


15-19 

20 24 


-21 

-47 


25-29 


-44 


30 34 


-33 


35 44 


-14 




+ 17 


55 Q4 


+24 




+ 7 




-35 







INFANTILE MORTALITY. 

Infantile mortality is tlie mortality of infants under 1 year of 
age. While the specific death rates for other age groups are given 
as the ratio of the "number of deaths to the number of individuals 
in the age group as ascertained by census enumeration and estimated 
for intercensal and post censal years, it is not practicable to do this 
for the first year of life. There is extreme difficulty in ascertaining 
by enumeration the infant population. This is due largely to con- 
fusion of the current year of age with the completed year of life. 
Many infants less than 12 months old are returned at the census as 1 
year of age. This causes an understatement of the infant population 
and gives an illusory basis for the estimation of infant mortafity rates. 

The commonly accepted method of stating infant mortality is 
as the ratio of deaths of children under 1 year of age to living births, 
and is usually expressed as the proportion of deaths during the calen- 
dar year to 1,000 living births durmg the same period. To illustrate: 
If m a city there were during a year 224 deaths of infants under 
1 year of age, and if during the same year there were 2,000 births, 
the infantile mortality rate would be 112 per 1,000 births per annum,. 

Infantile mortality rates might be based upon the number of 
births during the preceding year or upon the mean of the number 
of births of the current year and the precedmg year. However, the 
number of births of the current year has been accepted as the basis 
in Great Britain and many other countries. 



67 



Making the estimation of infantile mortality depend upon birth 
registration is at present unfortunate in a way for those interested 



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•^ 






























































[N 




/ 








N 






X 




























__ 


_ 






ba« 








_ 








-J 




_ 






>s 


I' 










v-i r 


^ 







Chaet 15. — Infantile mortality (deaths of infants under 1 year of age per 1,000 liirths per annum, ex- 
clusive of stillbiiths)— German Empire, France, England and Wales, Denmark, Sweden, and New- 
Zealand— 1892 to 1911. 



170 

160 
150 
140 




1845 


1850 


1855 


I860 


i865 


1870 


1875 


1880 


1885 


1890 


1895 


1900 


1905 


!9I0 


^ 




' 




































































































































































































1 
1 












































/ 


.^ 


— »= 












y 


-^ 








































/ 


/ 






^ 


•^ 






k" 






"^ 


\ 
















\y 


^' 


\ 
















y 


























N 










y 


y 






N 


^ 










































N 


s 


^ 


y 












\ 














































' 
















V 






























































\ 










fJU 




















































\ 


\ 








120 






















































\ 




























































y 








110 


























































































































100 






























































■nn 




_» 


«„ 


__ 




_ 




u»- 




























__ 






__ 


L_ 






n^ 



Chaet 16.— Infantile mortality (deatli-s of infants under 1 year of age per 1,000 births per annum, 
exclusive of stillbii-ths)— England and Wales— 1840 to 1910. The curve shows the mean annual rata 
for quinquemiial periods. 

in the subject as it relates to the United States, owing to deficient 
birth registration in this country and the impossibility therefore of 



estimating infantile mortality rates, except for certain limited areas. 
However, there is no other practicable basis for estimation. There 
are, too, other difficulties to be encountered in the use of incomplete 
birth registration. In the absence of change in other factors an 
improving completeness of bJTth registration would give an apparent 
decreasing infantile niortahty rate and might lead to unwarranted 
deductions. For a further discussion of the subject the reader is 
referred to a paper entitled, "Certain phases and fallacies of American 
mfant mortahty statistics," by Edward Bunnell Phelps,^ in the 
American Journal of Pubhc Health, Volume III, No. 11, November, 
1913. 

Table 11. — Infantile viortality — Deaths of children under 1 year of age per 1,000 births 
{exclusive of stillbirths') in certain countries, 1S92 and 1911.^ 



Country or State. 


1892 


1911 


Australian Commonwealth 


106 
259 
140 
148 
170 
181 


68 


Austria 


207 


Denmark 


106 


England and Wales . . . 


130 


Finland 


114 


France 


2 111 


German Empire 


192 


Hungary 


274 
105 
184 
174 
89 
105 
243 
117 
196 
109 


207 


Ireland ... . . 


94 


Italy 


2 142 


The Netherlands 


137 


New Zealand 


56 


Norway 


2 67 




197 


Scotland 


2 108 




2 138 


Sweden 


2 75 


Connecticut 


115 




161 


119 







1 Taken from the seventy-fourth annual report of the registrar general of births, deaths, and mar- 
riages in England and Wales, 1911, except the rates for Connecticut and Massachusetts, which were taken 
from State reports. 

2 Year 1910. 

LIFE TABLES. 

In theory life tables represent the duration of life of individuals 
born at the same time. Given a group of individuals born in any one 
year and a life table will show the number in the group that will stiU 
be alive in each succeeding yeeir as long as any remain. It will also 
show the number who will have died previous to any given year and 
the number dying during each year. To observe a group of indi- 
..viduals from the cradle to the grave is under most conditions imprac- 
ticable, and besides yields information the value of which is largely 
lost before it is obtained, for conditions affecting longevity may 
change and the life history of one generation may be quite different 
from that of the next. 



^ other papers on the subject by the same author are: "A statistical survey of infant mortality's urgent 
call for action," Transactions Am. Assn. for study and prevention of infant mortality, 1910. "A statistical 
study ot infant mortality," Quarterly publications, Am. Statistical Assn., Sept., 1908. "Infant mortality 
and its relation to woman's employment; A study of Massachusetts statistics," S. Doc. No. 645, 61st Cong., 
2d sess., 1912. 



Much of the value of a life table consists in showing current condi- 
tions as they affect the longevity of the community or race. For this 
purpose tables are constructed from the information furnished by an 
enumeration of the population (census) classified by age and sex and 
the registration of deaths with the decedents classified also by age and 
sex. The population age and sex groups give the number and pro- 
portion remaining alive at each year of age, the deaths show the num- 
ber dying at each year of age. For the purpose of getting data 
wiiich show general conditions prevailing durmg the period, and of 
avoiding the errors which might arise by using the death records of a 
year during which unusual mortality conditions prevailed, the death 
records for a number of consecutive years are usually used. 

Given the above data, the expectancy of life or mean after lifetime 
at a given age is readily obtained. The following table is one pre- 
pared under the direction of Dr. William H. GuiKoy, registrar of 
records of the New York City departm3nt of health and published in 
the monthly bulletin of the department for May, 1913. It compares 
the expectation of life based on the mortality experience of the three 
years 1909, 1910, and 1911, with that found by the late John S. 
Billings based upon the experience of 1879, 1880, and 1881: 

Table 12. — Approximate life tables for the city of New York based on mortality returns 
for the triennials 1879 to 1S81 and' 1909 to 1911. (Guilfoij.) 





Expectation of life 


, 1879 to 


Expectation of life 


, 1909 to 


Gain ( + 


or loss (— 


) in years 


Years of 




1881. 






1911. 




of 


expectancy. 


mortality. 








































Males. 


Females. 


Persons. 


Males. 


Females. 


Persons. 


Males. 


Females. 


Persons. 


Asjes: 




















— 5 


39.7 


42.8 


41.3 


50.1 


53.8 


51.9 


+10.4 


+ 11.0 


+10.6 


5 


44.9 


47.7 


46.3 


49.4 


52.9 


51.1 


+ 4.5 


+ 5.2 


+ 4.8 


10 


42.4 


45.3 


43.8 


45.2 


48.7 


46.9 


+ 2.8 


+ 3.4 


+ 3.1 


15 


38.2 


41.2 


39.7 


40.8 


44.2 


42.5 


+ 2.6 


+ 3.0 


+ 2.8 


20 


34.4 


37.3 


35.8 


36.6 


40.0 


38. 3 


+ 2.2 


+ 2.7 


+ 2.5 


25 


31.2 


34.0 


32.6 


32.7 


36.0 


34.3 


+ 1.5 


+ 2.0 


+ 1.7 


30 


28.2 


31.0 


29.6 


28.9 


32.1 


30.5 


+ 0.7 


+ 1.1 


+ 0.9 


35 


25.3 


28.1 


26.7 


25.4 


28.4 


26.9 


+ 0.1 


+ 0.3 


+ 0.2 


40 


22.5 


25.2 


23.9 


22.1 


24.7 


23.4 


- 0.4 


- 0.5 


- 0.5 


45 


19.8 


22.4 


21.1 


18.9 


21.1 


20.0 


- 0.9 


- 1.1 


- 1.1 


50 


17.2 


19.4 


18.3 


15.9 


17.7 


16.8 


- 1.3 


- 1.7 


- 1.5 


55 


14.5 


16.4 


15.4 


13.2 


14.6 


13.9 


- 1.3 


- 1.8 


- 1.5 


60 


12.2 


13.8 


13.0 


10.8 


11.8 


11.3 


- 1.4 


- 2.0 


- 1.7 


65 


9.9 


11.2 


10.5 


. 8.8 


9.4 


9.1 


- 1.1 


- 1.8 


- 1.4 


70 


8.5 


9.3 


8.9 


6.9 


7.5 


7.2 


- 1.6 


- 1.8 


- 1.7 


75 


7.1 


7.5 


7.3 


5.3 


5.7 


5.5 


- 1.8 


- l.S 


- l.S 


80 


6.2 


6.5 


6.4 


4.1 


4.5 


4.3 


- 2.1 


- 2.0 


- 2.1 


+85 


5.4 


5.5 


5.5 


2.0 


2.4 


2.2 


- 3.4 


- 3.1 


- 3.3 
















f +24.8 


+ 2S.7 


+26.6 
















{ -15.3 
i + 9.5 


-17.6 
+ 11.1 


-16.6 
















+ 10.0 



ACKNOWLEDGMENTS. 



It is a pleasure to the author to acknowledge his indebtedness to 
Drs. Cressy L. Wilbur, WiUiam H. Guilfoy, Jolm S. Fulton, and 
Charles F. Bolduan for many helpful suggestions. 



EARLY REGISTRATION IN ENGLAND. 

ORDER OF THOMAS CROMWELL, VICAR GENERAL UNDER HENRY VIII (l538) REQUIRING 
THE CLERGY TO RECORD BAPTISMS, MARRIAGES, AND BURIALS. 

"In the name of God Amen. By the au thorite and commission of the most excel- 
lent Prince Henry by the Grace of God Kynge of Englande and of France, defensor 
of the faithe Lorde of Irelande, and in erthe supreme hedd nndre Christ of the Church 
of Englande, I Thomas lorde Cromwell, lorde privie seall, Vicegerent within this 
realme, do for the advancement of the trewe honor of almighty God, encrease of vertu 
and discharge of the kynges majestic, give and exhibite unto you theise injunctions 
folowing, to be kept observed and fulfilled upon the paynes hereafter declared. 



"That you and every j^arson vicare or curate within this diocese shall for every 

churche kepe one boke or registere wherein ye shall w^ite the day and yere of every 

weddyng christenyng and buryeng made within yor parishe for your tyme, and so 

every man succeedyng you lykewyse. And shall there insert every persons name 

that shalbe so weddid christened or buried. And for the sauff kepinge of the same 

boke the parishe shalbe bonde to provide of these comen charges one sure coffer with 

twoo lockes and keys whereof the one to remayne with you, and the other with the 

said W9.rdens, wherein the saide boke shalbe laide upp. Whiche boke ye shall every 

Sonday take furtlie and in the presence of the said wardens or one of them v/rite and 

recorde in the same all the weddinges christenynges and buryenges made the hole 

weke before. And that done to lay upp the boke in the said coffer as afore. And for 

every tyme that the same shalbe omytted the partie that shalbe in the faulte thereof 

shall forfett to the saide churche Ills llld to be emploied on the rejjaration of the 

same churche. . v . 

"Thomas Crumwell." 



THE MODEL STATE LAW FOR MORBIDITY REPORTS. 

ADOPTED BY THE ELEVENTH ANNUAL CONFERENCE OP STATE AND TERRITORIAL HEALTH 
AUTHORITIES WITH THE UNITED STATES PUBLIC HEALTH SERVICE, MINNEAPOLIS, 

JUNE IG, 1913. 

A Bill To provide for the notification of the occurrenee and prevalence of certain diseases. 

Be it enacted by the Senate and General Assembly of the State of — : 

Section 1. It shall be, and is hereby, made the duty of the State department of 
health (or commissioner or board of health) to keep currently informed of the occur- 
rence, geographic distribution, and prevalence of the preventable diseases throughout 
the State, and for this purpose there shall be established in the State department of 
health a bureau (or division) of sanitary reports which shall, under the direction of 
the State commissioner of health (State health officer or secretary of the State board 
of health), be in charge of an assistant commissioner of health who shall receive an 

annual salary of dollars and the necessary expenses incurred in the performance 

of his duties. The State department of health shall provide such clerical and other 
assistance as may be necessary for the establishment and maintenance of said bureau. 

(71) 



72 



Sec. 2. Tlie following-named diseases and disabilities are hereby made notifiable 
and the occurrence of oases shall be reported as herein provided: 



GKOUP I.— INFECTIOUS DISEASES. 



Actmoinycosis. 
Anthrax. 
Chicken-pox. 

Cholera. Asiatic (also cholera nostras when Asiatic 
cholera is present or its importation threatened) 
Continued fever lasting seven days. 
Dengue. 
Diphtheria. 
Dysentery: 

(a) Amebic. 

(6) Bacillary. 
Favus. 

German measles. 
Glanders. 

Hookworm disease. 
Leprosy. 
Malaria. 
Measles. 
Meningitis: 

(a) Epidemic cerebrospinal. 

(6) Tuberculous. 
Mumps. 

Oplithalmia neonatorum (conjunctivitis of new- 
born infants). 
Paragonimiasis (endemic hemoptysis). 
Paratyphoid fever. 
Plague. 

Pneumonia (acute;. 
Poliomyelitis (acute infectious). 
Rabies. 

Rocky Mountain spotted, or tick, fever. 
Scarlet fever. 
Septic sore throat. 
Smallpox. 

Provided, That the State department of health (or board of health) may from time to 
time, in its discretion, declare additional diseases notifiable and subject to the pro- 
visions of this act. 

Sec, 3. Each and every physician practicing in the State of who treats or 

examines any person suffering from or afflicted Avith, or suspected to be suffering from 
or afflicted with, any one of the notifiable diseases shall immediately report such case 
of notifiable disease in writing to the local health authority having jurisdiction. Said 
report shall be forwarded either by mail or by special messenger and shall give the 
following information : 

1. The date when the report is made. 

2. The name of the disease or suspected disease. 

3. The name, age, sex, color, occupation, address, and school attended or place of 
employment of patient. 

4. Number of adults and of children in the household. 

5. Source or probable source of infection or the origin or probable origin of the 
disease. 

6. Name and address of the reporting physician. 

Provided, That if the disease is, or is suspected to be, smallpox the report shall, in 
addition, show whether the disease is of the mild or virulent type and whether the 
patient has ever been successfully vaccinated, and, if the patient has been success- 
fully vaccinated, the number of times and dates or approximate dates of such vaccina- 
tion; and if the disease is, or is suspected to be, cholera, diphtheria, plague, scarlet 
fever, smallpox, or yellow fever, the physician shall, in addition to the written report, 



Tetanus. 

Trachoma. 

Trichinosis. 

Tuberculosis (all forms, the organ or part afl'ected in 

each case to be specified). 
Typhoid fever. 
Tjfphus fever. 
Whooping cough. 
Yellow fever. 

GROUP n. — OCCUPATIONAL DISEASES AND INJURIES. 

Arsenic poisoning. 
Brass poisoning. 
Carbon monoxide poisoning. 
Lead poisoning. 
Mercury poisoning. 
Natural gas poisoning. 
Phosphorus poisoning. 
Wood alcohol poisonmg. 
Naphtha poisoning. 
Bisulphide of carbon poisoning. 
Dinitrobenzine poisoning. 
Caisson disease (compressed-air iUness). 
Any other disease or disability contracted as a result 
of the nature of the person's employment. 

GROUP m. — VENEREAL DISEASES. 

Gonococcus infection. 
Syphilis. 

GROUP IV.— DISEASES OF UNKNOWN ORIGIN. 

Pellagra. 
Cancer. 



73 

give immediate notice of the case to the local health, authority in the most expeditious 
manner available; and if the disease is, or is suspecteed to be, typhoid fever, scarlet 
fever, diphtheria, or septic sore throat the report shall also show whether the patient 
has been, or any member of the household in which the patient resides is, engaged or 
employed in the handling of milk for sale or preliminary to sale: And provided further , 
That in the reports of cases cf the venereal diseases the name and address of the patient 
need not be given. 

Sec. 4. The requirements of the preceding section shall be applicable to physicians 
attending patients ill with any of the notifiable diseases in hospitals, asylums, or other 
institutions, public or private: Provided, That the superintendent or other person in 
charge of any such hospital, asylum, or other institution in which the sick are cared 
for may, with the Written consent of the local health officer (or board of health) having 
jurisdiction, report in the place of the attending physician or physicians the cases of 
notifiable diseases and disabilities occurring in or admitted to said hospital, asylum, 
or other institution in the same manner as that prescribed by physicians. 

Sec. 5. Whenever a person is known, or is suspected, to be afflicted with a notifiable 
disease, or whenever the eyes of an infant under two weeks of age become reddened, 
inflamed, or swollen, or contain an unnatural discharge, and no physician is in attend- 
ance, an immediate report of the existence of the case shall be made to the local health 
officer by the midwife, nurse, attendant, or other person in charge of the patient. 

Sec. 6. Teachers or other persons employed in, or in charge of, public or private 
schools, including Sunday schools, shall report immediately to the local health officer 
each and every known or suspected case of a notifiable disease in persons attending 
or employed in their respective schools. 

Sec. 7. The written reports of cases of the notifiable disease required by this act of 
physicians shall be made upon blanks supplied for the purpose, through the local 
health authorities, by the State department of health. These blanks shall conform . 
to that adopted and approved by the State and Territorial health authorities in con- 
ference with the United States Public Health Service. 

Sec. -8. Local health officers or boards of health shall within seven days after the 
receipt by them of reports of cases of the notifiable diseases forward by mail to the 
State department of health the original written reports made by physicians, after 
first having transcribed the information given in the respective reports in a book or 
other form of record for the permanent files of the local health office. On each report 
thus forwarded the local health officer shall state whether the case to which the report 
pertains was visited or otherwise investigated by a representative of the local health 
office and whether measures were taken to prevent the sprea,d of the disease or the 
occurrence of additional cases. 

Sec. 9. Local health officers or boards of health shall, in addition to the i:)rovisions 
of section 8, report to the State department of health in such manner and at such 
times as the State department of health may require by regulation the number of new 
cases of each of the notifiable diseases reported to said local health officers or boards of 
health. 

Sec 10. Whenever there occurs within the jurisdiction of a local health officer or 
board of health an epidemic of a notifiable disease, the local health officer or board of 
health shall, within 30 days after the epidemic shall have subsided, make a rejwrt to 
the State department of health of the number of cases occurring in the epidemic, the 
number of cases terminating fatally, the origin of the epidemic, and the means by 
which the disease was spread: Provided, That whenever the State department of health 
has taken charge of the control and suppression or undertaken the investigation of the 
epidemic, the local health authority having jurisdiction need not make the report 
otherwise requhed. 

Sec. 11. No person shall be appointed to the position of local health officer in any 
city, town, or county until after the qualifications of said person have been approved 
by the State department of health. 



74 

Sec. 12. In localities in which there are no local health officers or boards of health, 
and in localities in which, although there are health officers or boards of health, 
adequate provision has not, in the opinion of the State department of health, been 
made for the proper notification, investigation, and control of notifiable disease, and 
in localities in which the local health authorities fail to carry out the provisions of 
this act, the State department of health shall appoint properly qualified sanitary 
officers to act as local health officers and to prevent the spread of disease in and from 
such localities and to enforce the provisions of this act: Provided, That salaries and 
other expenses incuiTed under the provisions of this section shall be paid by the local 
authorities. 

Sec. 13. Any physician or other person or pereons who shall fail, neglect, or refuse 
to comply with, or who shall violate any of the provisions of this act shall be guilty 
of a misdemeanor, and upon conviction thereof shall be sentenced to pay a fine of not 

less than dollars nor more than — • dollars or to imprisonment for not less 

than • days nor more than days for each offense: Provided, That in the 

case of a physician his license to practice medicine within the State may be revoked 
in accordance with existing statutory provisions. 

Sec. 14. No license to practice medicine shail be issued to any person until after 
the applicant shall have filed with the State licensing board a statement, signed and 
sworn to before a notary or other officer qualified to administer oaths, that said appli- 
cant has familiarized himself with the requirements of this act, a copy of which sworn 
statement shall be forwarded to the State department of health. 

Sec. 15. Each and every person engaged in the practice of medicine shall display 
in a pi'ominent place in his or her office a card upon which sections 2, 3, 4, 7, 13, 14, 
and 15 of this act have been printed with type not smaller than 10-point. A similar 
card shall be displayed in a prominent place in the office of each and every hospital, 
asylum, or other public or private institution for the treatment of the sick. These 
cards shall each be not less than 1 square foot in size and shall be furnished to insti- 
tutions and licensed physicians without cost by the State department of health. 

Sec. 16. The sum of dollars is hereby appropriated from any moneyin the 

State treasury not otherwise appropriated for carrying out the provisions of this act. 

Sec. 17. This act shall take effect immediately, and all acts or parts of acts incon-- 
sistent with the provisions of this act are hereby repealed. 



THE STANDARD MORBIDITY NOTIFICATION BLANK. 

The following model notification blank was also adopted by the conference of state 
and territorial health authorities with the United States Public Health Service 
June 16, 1913, as the standard notification blank referred to in section 7 of the 
Model Law as the one to be used in the reporting of cases of the notifiable diseases. 
This blank is intended to be printed on a post card : 

[Face of card.] 

,191... 

(Date.) 

Disease or suspected disease 

Patient's name , age , sex , color 

Patient's address , occupation 

School attended or place of emploj'ment 

Number in household: Adults , children 

Probable source of infection or origui of disease 

If disease is smallpox, tjTpe , number of times 

successfully vaccinated and approximate dates 

If typhoid fever, scarlet fever, diphtheria, or septic sore throat, vras patient, or is any member of household 

engaged in the production or handling of mUk 

Address of reporting physician 

Signature of physician 



75 



[Reverse of card.] 



For use of local health department. 



P ° s! 



n- Ei 



Health Department 

(City) 

(State)... 



HOSPITAL DISCHARGE CERTIFICATE. 

Suggested by Bolduan for use in connection with hospital morhiditu reporl 
DISCHARGE CERTIFICATE. 

Name of hospital Hospital admission No 

Sex Age 

How admitted — Ambulance — 



or 



O'mi application 
or 
(Tabulation transfer from 

No.) other hospital. 



White. 

Colored. 

Mongolian. 



Hebrew. 
Gentile. 



Place of birth . 



Patient's address Single or manied or widowed or divorced or un- 

Borough known. 

Date admitted Discharged to— 

Date dischai-ged Home. 

Days in hospital months ■ Other hospital. 

daj'S Convalescent retreat. 

(If over a year, omit the days and give only years and Coroner. 

months.) 
Occupation — (a) Trade, profession, or pai'ticular kind of v.^ork. 

(b) General natm'e of the industry, business, or establishment in wjiich employed (or em- 
ployer). 



Diagnosis 

and 
Complications 

If operated upon, state nature of operation 

Condition on dischaige: Cured. Improved. Unimproved. 

Died — Autopsy. 

No autopsy. 
Signed 



House Physician— Sm-geou. 



76 

NOTIFICATION OF OCCUPATIONAL DISEASES, UNITED STATES. 
Abstracts of the State Laws and Regulations. 

CALIFORNIA. 

Medical practitioners are to report all cases among their patients of poisoning by- 
lead, phosphorus, arsenic, or mercury or their compounds, of anthrax and of com- 
pressed-air illness, contracted as a result of the nature of tbe patient's employment. 
These reports are to be made at once to the State board of health and to give the name, 
address, and place of employment of the patient, and name of the disease from which 
the patient is supposed to be suffering. 

Physicians are entitled to a fee of 50 cents for each report forwarded. 

Willful failure on the part of a physician to report is made a misdemeanor punish- 
able by a fine of not more than §10. 

The law is to be enforced by the State board of health, which may call upon local 
health authorities for assistance. 

The State board of health upon receipt of reports of occupational diseases as above 
described is to transmit the data to the commissioner of the bureau of labor statistics. 
(Chap. 485, Acts of 1911.) 

CONNECTICUT. 

Physicians are to report all cases known to them of occupational diseases, that is, 
diseases contracted as a result of the nature of the patient's employment. The law 
names specifically poisoning from lead, phosphorus, arsenic, brass, wood alcohol, and 
mercury and their compounds, anthrax and compressed-air illness. The reports are 
to be made witliin 48 hours by mail to the commissioner of the bureau of labor statistics 
and are to show the name, address, and occupation of the patient, the name, address, 
and business of the patient's employer, the nature of the disease, and such other infor- 
mation as may be required by the commissioner. Blank forms upon wliich to make 
these reports are furnished by the bureau of labor statistics. 

Failure on the part of a physician to report within the time specified is made pun- 
ishable by a fine of not to exceed $10. (Chap. 14, Act approved Apr. 22, 1913.) 



In the Illinois law industries in which sugar of lead, white lead, lead chromate, 
litliarge, red lead, or arsenate of lead are used or handled in any way, and industries 
engaged in the manufacture of brass or the smelting of lead or zinc are declared to be 
especially dangerous to the health of the employees. Employers engaged in carrying 
on these industries are required to cause all employees who come in direct contact 
with the poisonous agencies or injurious processes to be examined once a month by a 
physician to ascertain whether there exists in the employees any occupational disease 
or illness due or incident to the character of their work. The physicians making these 
examinations are to report immediately to the State board of health. If no occupa- 
tional disease is found, the report is to so state. If a case of occupational disease is 
found, the report is to state the name, address, sex, age, and last place of emrjloyment 
of the employee affected, the name of the employer, and the nature of the disease and 
its probable extent and duration. Upon the receipt of such a report the secretary of 
the State board of health is to immediately transmit a copy of it to the Illinois depart- 
ment of factory inspection. (Act approved May 26, 1911; effective July 1, 1911.) 



The State Board of Health of Kansas by regulations, adopted December 13, 
1913, made the following occupational diseases notifiable to the State health depart- 
ment through the local health departments in the same manner as the other notifiable 



77 

diseases: Arsenic poisoning, brass poisoning, carbon monoxide poisoning, lead poison- 
ing, mercury poisoning, natural gas poisoning, phosphoriis poisoning, wood alcoliol 
poisoning, naplitha poisoning, bisulpliide of carbon poisoning, dinitrobenzine poison- 
ing, caisson disease (compressed-air illness). Any otlier disease or disability con- 
tracted as a result of tlie nature of tlie person's employment. 



Physicians are to report all cases among their patients of poisoning from lead, 
phosphorus, arsenic, or mercury, or their compounds, of anthrax, of compressed-air 
illness, or of any other disease or ailment contracted as a result of the patient's occu- 
pation or employment. The reports are to be made in writing to the State board of 
health within 10 days after first seeing the patient, and are to give the name, address, 
nature of the occupation and place of employment of the patient, the nature of the 
disease, and such other information as may be required by the State board of health. 
In like manner physicians are to report all cases of lead poisoning or suspected lead 
poisoning resulting from the use of water suspected of containing lead. 

Failure on the part of the physician to make these reports is made a misdemeanor 
punishable by a fine of not less than $5 nor more than $10. 

The enforcement of the law is imposed on the State board of health and the county 
attorneys. (Chap. 82, act approved Mar. 20, 1913.) 

MARYLAND. 

Physicians are required to report all cases in which the patients are believed to 
be suffering from poisoning from lead, phosphorus, arsenic or mercury or their com- 
pounds, or from anthrax or compressed-air illness, or from any other ailment con- 
tracted as a result of the nature of the patient's employment. These reports are to be 
made at once in writing to the State board of health and are to give the name, address, 
occupation, and place of employment of the patient, the nature of the disease, and 
Buch other information as may be required by the State board of health. 

The State board of health is to enforce the act and to transmit the data received 
in the reports from physicians to the chief of the Maryland bureau of statistics and 
information . 

Failure on the part of a physician to make the required reports renders him liable 
to a fine of not to exceed $5. (Act approved Apr. 8, 1912.) 

MASSA.CHUSETTS . 

The State board of labor and the industrial accident board, sitting jointly, are to 
make regulations for the prevention of occupational diseases and are given the 
authority to require physicians to report all cases among their patients of diseases 
contracted as a result of the nature, circumstances, or conditions of the patient's 
employment, and to fix the information to be furnished and the time within which 
such reports shall be made. These reports are to be made to the State board of labor 
and industries. 

Violations of any regulations made as described above are punishable by a fine of 
not more than $100 for each offense. (Act approved June 16, 1913.) 

MICHIGAN. 

Physicians are to report all cases among their patients of poisoning from lead, phos- 
phorus, arsenic or mercury or their compounds, of anthrax or of compressed-air illness, 
contracted as a result of the nature of the patient's employment. These reports are to 
be made to the State board of health and are to give the name, address, and place and 
duration of employment of the patient and the nature of the disease from which, in 
the opinion of the physician, the patient is suffering. 

The State board of health is to transmit these reports to the commissioner of labor. 



78 

Failure on the part of a physician, to make these reports is made a misdemeanor 
punishable by a fine of not more than $5. 

It is made the duty of the commissioner of labor and the county attorneys to prose- 
cute violations of the law. (Act approved Apr. 25, 1911.) 

MINNESOTA . 

Physicians are to report all cases in which the patient is believed to be suffering from 
poisoning from lead, phosphorus, arsenic or mercury or their compounds, or from 
anthrax or compressed-air illness, contracted as a result of the nature of the patient's 
employment. The reports are to be made at once to the commissioner of labor and 
are to give the name, address, and place of employment of the patient, the nature of 
the disease ,_ and such other information as may be required by the commissioner of 
labor. 

Enforcement of the law is made the duty of the commissioner of labor, who may 
call upon the State and local boards of health for assistance. 

Failure on the part of a physician to make the required reports is made a misde- 
meanor, punishable by a fine of not more than |10 or by iniprisonment for not exceeding 
10 days. (Act approved Feb. 25, 1913 j effective aiter July, 1913.) 

MISSOURI. 

Employees engaged in manufacture in which antimony, arsenic, brass, copper, 
lead, mercury, phosphorus, zinc, their alloys or salts or any poisonous chemicals, 
minerals, acids, fimies, vapors, gases or other substances are generated, used, or han- 
dled by employees in harmful quantities, or under harmful conditions, are required 
at least once a month to cause all employees coming into direct contact with the 
poisonotis agencies to be examined by a physician to ascertain whether there exists 
in the employees ajiy disease due or Incident to the character of the work in which 
the employees are engaged. The physicians making these exajninations are to make 
within 24 hours a report to the State hosxd of health in triplicate upon blanks f lu-nished 
by said board. If disease incident to occupation is found, the report is to state the 
name, address, and business of the employer, the nature of the disease, and its probable 
extent and duration, the name of the employee and his last place and length of em- 
ployment. 

Upon receipt of these reports the secretary of the State board of health is to send 
one copy to the State factory inspector and one copy to the superintendent of the fac- 
tory in which the employee is supposed to have contracted Ids ailment. 

The enforcement of the law is made the duty of the State factory inspector. 

Failure on the part of a physiciaia. to make the required reports is made a misde- 
meanor punishable by a fine of not less than $50. (Act approved Mar. 27, 1913; 
effective June 23, 1913.) 

NEW HAMPSHIRE. 

Physicians are to report all cases among their patients believed to be suffering from 
poisoning from lead, phosphorus, arsenic, brass, wood alcohol, or mercury or their 
compounds or from anthrax or compressed-air illness or any other ailment contracted 
as a result of the nature of the patient's employment. These reports are to be made 
to the State board of health within 48 hoiura and are to give the name, address, and 
occupation of the patient, the name, address, and business of the employer, the nature 
of the disease, and such other information as may be required by the State board of 
health. 

The State board of health is to prepare and issue blank forms on which the reports 
are to be made by physicians and is to transmit copies of reports received to the com- 
missioner of labor. 

Violations of the law on the part of physicians are made punishable by a fine of |5 
for each offense. (Act approved May 7, 1913; effective July 1, 1913.) 



79 

NEW JERSEY. 

Physicians are to report all cases in which, the patients are believed to be suffering 
from poisoning from lead, phosphorus, arsenic, or mercury or their compounds, or 
from anthrax or compressed-air illness contracted as a result of the patient's employ- 
ment. The reports are to be made in writing to the State board of health within 30 
days after the first visit and are to give the name, address, occupation, and place of 
employment of the patient, the name of the disease and such other information as may 
be required by the State board of health. 

The enforcement of the law is made the duty of the State board of health wliich 
is to transmit the data received in the reports of physicians to the commissioner of 
labor. 

Failure to report renders a physician liable to a fine of |25 for each offense. (Act 
approved Apr. 1, 1913.) 

NEW YORK. 

Medical practitioners are to report all cases in which the patients are believed to be 
suffering from poisoning from lead, phosphorus, arsenic, brass, wood alcohol, or mer- 
cury or their compounds, or from antlu'ax or compressed-air illness, contracted aa the 
result of the nature of the patient's employment. These reports ai-e to be made at 
once to the commissioner of labor and are to give the name, address, and place of 
employment of the patient, the name of the disease, and such other information aa 
may be reo^uired by the commissioner. 

The enforcement of the law is made the duty of the commissioner of labor who ia 
authorized to call upon the State and local boards of health for assistance. 

Failure to report renders a physician liable to a fine of not to exceed $10. (Act 
approved June 6, 1911; effective Sept. 1, 1911; amended by chap. 145; approved 
Mar. 28, 1913.) 

OHIO. 

The Ohio law enacted April 23, 1913, is the same as that of New Hampshire with 
the exception that there is no penalty for ^iolations, and the State board of health 
is to transmit copies of reports received to "the proper officials having charge of 
factory inspection" instead of to the "commissioner of labor" as in New Hampshire. 

A law enacted May 6, 1913, and effective October 1, 1913, requires employers to 
have all employees who are engaged in the manufacture of white lead, red lead, 
litharge, sugar of lead, arsenate of lead, lead chromate, lead sulphate, lead nitrate, 
or fluosilicate and are exposed to lead dusts, fumes, or solutions, examined at least 
once a month by a physician to ascertain whether there exist symptoms of lead poison- 
ing. If symptoms believed to be due to lead poisoning are found, the examining 
physician is to make within 48 hours a report in duplicate and send one copy to the 
State board of health and the other to the State department of factory inspection. 
The reports are to be upon or in conformity with blanks furnished for the purpose 
by the State board of health, and are to give the name, occupation, and address of 
the employee, the name, business, and address of the employer, the nature and 
probable extent of the disease, and such other information as may be required by the 
State board of health. The examining physician is also to report his findings within 
48 hours to the employer. 

The law is to be enforced by the State department of factory inspection. 

PENNSYLVANIA. 

Employers are to cause all employees who are exposed to lead dusts, fumes, or 
solutions while engaged in the manufacture of lead, lead chromate, lead sulphate, 
lead nitrate, or fluosilicate to be examined by a physician at least once a month to 



80 

ascertain wlietlier symptoms of lead poisoning exist. Physicians making tliese exami- 
nations are to make a report in duplicate on or in conformity with forms furnished 
by the State department of health. These reports are to be sent within 48 hours, 
one copy to. the State department of health and one copy to the State department 
of labor and industry. The reports are to show the name, occupation, and address 
of the employee, the name, business, and address of the employer, the nature and 
probable extent of the disease, and such other information as may be required by 
the State department of health; the physician is also to report his findings witliin 48 
hours to the employer. 

The enforcement of the law is made the duty of the State department of labor and 
industry. (Act approved July 26, 1913; effective Oct. 1, 1913.) 

WISCONSIN. 

Medical practitioners are to report all cases in wliich the patients are believed to 
be suffering from poisoning from lead, phosphorus, arsenic, or mercury, or their com- 
pounds, or from compressed-air illness, contracted as a result of the nature of the 
patient's employment. The reports are to be made to the secretary of the State board 
of health and are to give the name, address, and place of employment of the patient 
and the nature of the disease. 

The enforcement of the law is made the duty of the commissioner of labor and indus- 
trial statistics, who is authorized to call upon the State and local boards of health for 
assistance. 

Violation of the act on the jjart of physicians is made punishable by a fine of not 
more than §10. (Act approved June 2, 1911.) 



In the tables wliich follow an attempt has been made to show briefly in tabular form 
the essential requirements of the several State lav/s relating to the notification by 
physicians of cases of occupational and industrial diseases. It has not been possible 
in all instances to show the requirements accurately in this way. 

Occupational diseases required by State laws to he reported. 





Poisoning by- 


An- 
thrax. 


Com- 
pressed- 
air ill- 
ness. 


AR oc- 
cupa- 
tional 
dis- 
eases. 




Lead or 
its com- 
pounds. 


Phos- 
phorus 
or its 
com- 
poiuids. 


Arsenic 
or its 
com- 
pounds. 


Mer- 
ciu-y or 
its com- 
pounds. 


Brass. 


Wood 
alcohol. 




X 
X 
X 
X 
X 
X 


X 
X 


X 
X 


X 






X 

X 


X 
X 






X 


X 


X 








X 
X 
X 


X 
X 
X 


X 
X 
X 


X 


X 


X 
X 
X 


X 
X 
X 


X 




X 








X 












X 
X 


X 
X 


X 
X 


X 
X 






X 
X 


X 
X 


















X 




X 
X 
X 
X 
X 
X 


X 
X 
X 
X 


X 
X 
X 
X 


X 
X 
X 
X 


X 


X 


X 
X 
X 
X 


X 
X 
X 
X 


X 








X 
X 


X 
X 




Ohio 


X 








X 


X 


X 








X 















1 The Kansas requirements are by regulations adopted by the State board of health in December, 1913. 

2 Authority is given to the State board of labor and the industrial accident board, sitting jointly, to pro- 
mulgate regulations requiring the reporting of occupational diseases. These had not been promulgated up 
to Dec. 1, 1913. 



81 



Occupational diseases. — Information to be given in reports by physicians. 







Of patient. 


Of employer. 




States. 




i 
1 


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tl 
ft 

i 

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e ■ 

OS 

S.2 
s p. 


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And such other infor- 
mal ion as may be 
required by— 


California 


X 
X 

X 
X 
X 

X 


X 
X 

X 
X 
X 
X 


"x" 

X 
X 

X 


X 




X 
X 

X 
X 
X 
X 














X 


X 
X 


X 


X 


Bm-eau of labor sta- 
tistics. 


Illinois 


X 
X 
X 




Kansas 








Maryland 












Maine. 










Do 


Massachusetts 
















Michigan 


X 
X 


X 
X 




X 
X 

X 


X 
X 


X 
X 

X 
X 












Minnesota 












Missouri 


X 


X 
X 


X 
X 


X 
X 


bor. 


New Hampshire. . 
New Jersey 


X 
X 

X 

X 
X 

X 


X 
X 

X 

X 
X 

X 


X 
X 

X 
X 

X 




X 

X 




Do. 


New York 
















Ohio 




X 
X 

X 










bor. 
State board of health. 


Pennsylvania 

Wisconsin . . 














State department of 
health. 































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83 

THE MODEL STATE LAW FOR THE REGISTRATION OF BIRTHS AND 

DEATHS. 

A Billi To provide for the registration of all births and deaths in the State of . 



Note.— After the bill has been prepared for presentation to the legislature of a State, the title should 
be carefully revised by competent legal authority. 

Be it enacted by the legislature of the State of 



Section 1. Tliat the State board of health shall have charge of the registration of 
births and deaths; shall prepare the necessary instructions, forms, and blanks for 
obtaini n g and preserAing siich records and shall procure the faithful registration of 
the same in each primary registration district as constituted in section 3 of this act, 
and in the central btireau of A-ital statistics at the capital of the State. The said board 
shall be charged with the uniform and thorough enforcement of the law throughout 
the State, and shall from time to time recommend any additional legislation ^ that 
may be necessary for this purpose. 

Sec. 2. That the secretary of the State board of health shall have general superAdsion 
over the central bureau of vital statistics, wliich is hereby authorized to be estab- 
lished by said board, and which shall be under the immediate direction of the State 
registrar of vital statistics, A^hom the State board of health shall appoint witliin thirty 
days after the taking effect of this law, and who shall be a medical practitioner of not 
less than five years' practice in his profession, and a competent vital statistician. 
The State registrar of vital statistics shall hold ofiice for four years and until his suc- 
cessor has been appointed and has qualified, unless such ofiice shall sooner become 
vacant by death, disqualification, operation of law, or other causes. Any vacancy 
occurring in such office shall be filled for the imexpired term by the State board of 
health. At least ten days before the expiration of the term of office of the State 
registrar of vital statistics, his successor shall be appointed by the State board of 
health. The State registrar of vital statistics shall receive an annual salary at the 
rate of — — ■ — dollars from the date of his entering upon the discharge of the duties 
of his ofiice. The State board of health shall provide for such clerical and other 
assistants as may be necessary for the purposes of this act, who shall serve during 
the pleasure of the board, and shall fix th-e compensation of persons thus employed 
within the amount appropriated therefor by the legislature. The custodian of the 

capitol shall provide for the bureau of idtal statistics in the State capitol at 

eiu table offices, which shall be properly equipped with fireproof vault and filing cases 
for the permanent and safe preservation of all official records made and returned 
under this act. 

Sec. 3. That for the purposes of this act the State shall be di\^ded into registration 
districts as follows: Each city, each incorporated town, and each townshij?^ shall 
constitute a primary registration district: Provided, That the State board of health 
may combine two or more primary registration districts when necessary to facilitate 
registration. 

Sec. 4. That within ninety days after the taking effect of this act, or as soon thereafter 
as possible, the State board of health shall appoint a local registrar of vital statistics 

1 Before introducing this biil in any legislature it should be carefully redrafted by a competent law-yer 
and submitted to the Bureau of the Census for criticism. 

2 The words "and shall promulgate any additional rules or regulations " may be inserted in bills prepared 
for States in which the State board of health has power to make rules and regxilations having the effect 
of law. 

' Or other primary political unit, as "town," "precinct," "civil district," "hundred," etc. "When 
there are no such units available , the following substitutes for section 3 may be employed: Section 3. That 
for the purposes of this act the State shall be divided into registration districts as follows: Each city and 
each incorporated town shall constitute a primary registration district; and for that portion of each c-ounty 
outside of the cities and incorporated towns therein the State board of health shall define and designate 
the boundaries of a sufficient number of rural registration districts, which districts it may change or com- 
bine from time to time as may be necessary to insure the convenience and completeness of registration. 



84 

for each registration district in the State. ^ The term of office of each local registrar so 
appointed shall be four years, and until his successor has been appointed and has quali- 
fied, unless such office shall sooner become vacant by death, disqualification, opera- 
tion of law, or other causes: Provided, That in cities where health officei-s or other 
officials are, in the judgment of the State board of health, conducting effective regis- 
tration of births and deaths under local ordinances at the time of the taking effect of 
this act such officials may be appointed as registrars in and for such cities, and shall 
be subject to the rules and regulations of the State registrar and to all of the provisions 
of this act. Any vacancy occurring in the office of local registrar of vital statistics 
shall be filled for the unexphed term by the State board of health. At least ten days 
before the expiration of the term of office of any such local registrar his successor shall 
be appointed by the State board of health. 

Any local registrar who, in the judgment of the State board of health, fails or neg- 
lects to discharge efr.ciently the duties of his office as set forth in this act, or to make 
prompt and complete returns of bhths and deaths as requhed thereby, shall be forth- 
with removed by the State board of health, and such other penalties may be imposed 
as are provided under section 22 of this act. 

Each local registrar shall, immediately upon his acceptance of appointment as such, 
appoint a deputy, whose duty it shall be to act in his stead in case of his absence or 
disability; and such deputy shall in writing accept such appointment and be sub- 
ject to all rules and regulations governing local registrars. And when it appears 
necessary for the convenience of the people in any rural district the local registrar is 
hereby authorized, -sWth the approval of the State registrar, to appoint one or more 
suitable persons to act as subregistrars, who shall be authorized to receive certificates 
and to issue burial or removal permits in and for such portions of the district as may 
be designated; and each subregistrar shall note on each certificate, over his signature, 
the date of filing, and shall forv/ard all certificates to the local registrar of the district 
within ten days, and in all cases before the third day of the following month: Pro- 
vided, That each subregistrar shall be subject to the supervision and control of the 
State registrar and may be by him removed for neglect or failure to perform his duty 
in accordance with the provisions of this act or the rules and regulations of the State 
registrar, and shall be subject to the same penalties for neglect of duty as the local 
registrar. 

Sec. 5. That the body of any person whose death occurs in this State, or which 
shall be found dead therein, shall not be interred, deposited in a vault or tomb, 
cremated or otherwise disposed of, or removed from or into any registration district, 
or be temporarily held pending further disposition more than seventy-two hours after 
death, unless a permit for burial, removal, or other disposition thereof shall have 
been properly issued by the local registrar of the registration district in which the 
death occurred or the body was found. ^ And no such burial or removal permit shall 
be issued by any registrar until, wherever practicable, a complete and satisfactory 
certificate of death has been filed with him as hereinafter provided: Provided, That 
when a dead body is transported from outside the State into a registration district 

in — • for burial, the transit or removal permit, issued in accordance with the law 

and health regulations of the place where the death occurred, shall be accepted by 
the local registrar of the district into which the body has been transported for burial 
or other disposition, as a basis upon which he may issue a local burial permit; he shall 
note upon the face of the burial permit the fact that it was a body shipped in for 

1 This method of appointment of local registrars by the State board of health— or perhaps by the State 
registrar or upon his nomination— with a reasonably long term of service and subject to removal for neglect 
of duty, is the preferable one for efhcient service. Should there be objection, however, to the creation of 
new offices, the section may be redrafted so that it will provide that township, village, or city clerks, or 
other suitable officials, shall be the local registrars. 

2 A special proviso may be required for sparsely settled portions of a State. 



85 

interment, and give the actual place of death; and no local registrar shall receive any 
fee for the issuance of burial or removal permits under this act other than the com- 
pensation provided in section 20. 

Sec. 6. That a stillborn child shall be registered as a birth and also as a death, and 
separate certificates of both the birth and the death shall be filed with the local regis- 
trar, in the usual form and manner, the certificate of birth to contain in place of the 
name of the child, the word "stillbirth": Provided, That a certificate of birth and a 
certificate of death shall not be required for a child that has not advanced to the fifth 
month of uterogestation. The medical certificate of the cause of death shall be 
signed by the attending physician, if any, and shall state the cause of death as 
"stillborn," with the cause of the stillbirth, if known, whether a premature birth, 
and, if born prematurely, the period of uterogestation, in months, if known; and a 
burial or removal permit of the prescribed form shall be required. Midwives shall 
not sign certificates of death for stillborn children; but such cases, and stillbirths 
occurring without attendance of either physician or midwife, shall be treated as 
deaths without medical attendance, as provided for in section 8 of this act. 

Sec. 7. That the certificate of death shall contain the following items, which are 
hereby declared necessary for the legal, social, and sanitary purposes subserved by 
registration records: ^ 

(1) Place of death, including State, county, township, village, or city. If in a city, 
the ward, street, and house number; if in a hospital or other institution, the name of 
the same to be given instead of the street and house number. If in an industrial camp, 
the name of the camp to be given. 

(2) Full name of decedent. If an unnamed child, the surname preceded by 
"Unnamed." 

(3) Sex. 

(4) Color or race, as white, black, mulatto (or other negro descent), Indian, Chinese, 
Japanese, or other. 

(5) Conjugal condition, as single, married, widowed, or divorced. 

(6) Date of birth, including the year, month, and day. 

(7) Age, in yea.rs, months, and days. If less than one day, the hours or minutes. 

(8) Occupation. The occupation to be reported of any person, male or female, who 
had any remunerative employment, with the statement of (a) trade, profession or 
particular kind of work; (&) general nature of industry, business^ or establishment in 
which employed (or employer). 

(9) Birthplace; atleast State or foreign country, if known. 

(10) Name of father. 

(11) Birthplace of father; at least State or foreign countrj^, if known. 

(12) Maiden name of mother. 

(13) Birthplace of mother; at least State or foreign country, if known. 

(14) Signature and address of informant. 

(15) Official signature of registrar, with the date when certificate was filed, and 
registered number. 

(16) Date of death, year, month, and day. 

(17) Certification as to medical attendance on decedent, fact and time of death, time 
last seen alive, and the cause of death, with contributory (secondary) cause of compli- 
cation, if any, and duration of each, and whether attributed to dangerous or insanitary 
conditions of employment; signature and address of physician or official making the 
medical certificate. 

(18) Length of residence (for inmates of hospitals and other institutions; transients 
or recent residents) at place of death and in the State, together with the place where 
disease was contracted, if not at place of death, and former or usual residence. 



1 The following items are those of the United States standard certificate of death, approved by the Bureau 
of the Census. 



86 

(19) Place of burial or removal; date of burial. 

(20) Signature and address of undertaker or person acting as such. 

The personal and statistical particulars (items 1 to 13) shall be authenticated by the 
signature of the informant, who may be any competent person acquainted with the 
facts. 

The statement of facts relating to the disposition of the body shall be signed by the 
undertaker or person acting as such. 

The medical certificate shall be made and signed by the physician, if any, last in 
attendance on the deceased, who shall specify the time in attendance, the time he 
last saw the deceased alive, and the hour of the day at which death occurred. And he 
shall further state the cause of death, so as to show the course of disease or sequence of 
causes resulting in the death, giving first the name of the disease causing death 
(primary cause), and the contributory (secondary) cause, if any, and the duration of 
each. Indefinite and unsatisfactory terms, denoting only symptoms of disease or 
conditions resulting from disease, will not be held sufficient for the issuance of a burial 
or removal permit; and any certificate containing only such terms as defined by the 
State Kegistrar shall be returned to the physician or person making the medical 
certificate for correction and more definite statement. Causes of death which may be 
the result of either disease or violence shall be carefully defined; and if from violence, 
the means of injury shall be stated and whether (probably) accidental, suicidal, or 
homicidal.^ And for deaths in hospitals, institutions, or of nonresidents the physician 
shall supply the information required under this head (item 18), if he is able to do so, 
and may statd*where, in his opinion, the disease was contracted. 

Sec. 8. That in case of any death occurring without medical attendance it shall be 
the duty of the undertaker to notify the local registrar of such death, and when so 
notified the registrar shall, prior to the issuance of the permit, inform the local health 
officer and refer the case to him for immediate investigation and certification: Pro- 
vided, That when the local health officer is not a physician, or when there is no such 
official, and in such cases only, the registrar is authorized to make the certificate and 
return from the statement of relatives or other persons having adequate knowledge of 
the facts: Provided further , That if the registrar has reason to believe that the death 
may have been due to unlawful act or neglect he shall then refer the case to the coroner 
or other proper officer for his investigation and certification. And the coroner or 
other proper officer whose duty it is to hold an inquest on tlie body of any deceased 
person and to make the certificate of death required for a burial permit shall state in 
his certificate the name of the disease causing death, or if from external causes, (1) the 
means of death and (2) whether (probably) accidental, suicidal, or homicidal, and 
shall in any case furnish such information as may be required by the State Registrar 
in order properly to classify the death. 

Sec. 9. That the undertaker or person acting as imdertaker shall file the certificate 
of death with the local registrar of the district in which the death occurred and obtam 
a burial or removal permit prior to any disposition of the body. He shall obtain the 
required personal and statistical particulars from the person best qualified to supply 
them, over the signatiu-e and address of his informant. He shall then present the 
certificate to the attending physician, if any, or to the health officer or coroner, as 
directed by the local registrar, for the medical certificate of the cause of death and 
other particulars necessary to complete the record, as specified in sections 7 and 8. 
And he shall then state the facts required relative to the date aud place of burial or 
removal, over his signature aud with his address, and present the completed certificate 
to the local registrar in order to obtain a permit for burial, removal, or other disposition 
of the body. The undertaker shall deliver the burial permit to the person in charge 

1 In some States the question whether a death was accidental, suicidal, or homicidal must be determined 
by the coroner or medical examiner, and the registration law must be framed to hai-mouize. 



87 

of the place of bui-ial before interring or otherwise disposing of the body, or shall 
attach the removal permit to the box containing the corpse, when shipped by any 
transportation company, said permit to accompany the corpse to its destination, 

where, if within the State of , it shall be deli^^ered to the person in charge of the 

place of burial. 

[Every person, fii'm, or corporation selling a casket shall keep a record showing the 
name of the pmxhaser, j^urchaser's post-office address, name of deceased, date of 
death, and place of death of deceased, which record shall be open to inspection of the 
State Registrar at all times. Oa the fii'st day of each month the pei'sou, firm, or corpo- 
ration selling caskets shall report to the State Registrar each sale for the precediog 
month, on a blank provided for that piu'pose: Provided, however, That no person, firm, 
or corporation selling caskets to dealers or undertakers only shall be required to keep 
such record, nor shall such report be required from undertakers when they have direct 
charge of the disposition of a dead body. 

E\ery person, fii-m, or corporation selling a casket at retail, and not having charge of 
the disposition of the body, shall inclose within the casket a notice furnished by the 
State Registrar calling attention to the requirements of the law, a blank certificate of 
death, and the rules and regidations of the State board of health concerning the bmial 
or other disi>osition of a dead body.]^ 

Sec. 10. That if the interment or other disposition of the body is to be made within 
the State, the wording of the burial or removal permit may be limited to a statement 
by the registrar, and over hie signature, that a satisfactory certificate of death having 
been filed with him, as required by law, permission is granted to inter, remove, or 
dispose otherwise of the body, stating the name, age, sex, cause of death, and other 
necessary details upon the form prescribed by the State registrar. 

Sec. 11. That no person in charge of any premises on which interments are made 
shall inter or permit the interment or other disposition of any body unless it is accom- 
panied by a burial, removal, or transit permit, as herein provided. And such peraon 
shall indorse upon the permit the date of interment, over his signature, and shall 
return all permits so indorsed to the local registrar of his district within ten days from 
the date of interment, or within the time fixed by the local board of health. He shall 
keep a record of all bodies interred or otherwise disposed of on the premises under 
his charge, in each case stating the name of each deceased person, place of death, 
date of burial or disposal, and name and address of the undertaker; which record 
shall at all times be open to official inspection: Provided, That the undertaker, or per- 
son acting as such, when burying a body in a cemetery or burial ground having no 
person in cliarge, shall sign the burial or removal permit, giving the date of bm-ial, 
and shall write across the face of the permit tire words "No person in charge," and 
file the burial or removal permit within ten days with the registrar of the district in 
which the cemetery is located. 

Sec. 12. That the birth of each and every child born in this State shall be registered 
as hereinafter provided. 

Sec 13. That within ten days after the date of each bu-th there shall be filed with 
the local registrar of the district in which the birth occurred a certificate of such bii'th, 
which certificate shall be upon the form adopted by the State board of health with a 
view to procuring a full and accurate report with respect to each item of information 
enumerated in section 14 of this act.^ 

In each case where a physician, midwife, or person acting as midwife was in attend- 
ance upon the birth, it shall be the duty of such physician, midwife, or person acting 
as midwife to file in accordance herewith the certificate herein contemplated. 

1 The provisions in brackets may be useful in States in ^vhich many funerals are conducted without 
regular undertakers. 

2 A proviso may be added that shall require the registration, or notification, at a shorter interval than 
ten days, of births that occur in cities. 



m each case v^liere there was no physician, midwife, or person acting as midwife 
in attendance njDon the birth, it shall be the duty of the father or mother of the child, 
the householder or owner of the premises where the birth occurred, or the manager or 
superintendent of the public or private institution where the birth occurred, each in 
the order named, within ten days after the date of such bhth, to report to the local 
registrar the fact of such birth. In such case and in case the physician, midwife, or 
person acting as midwife, in attendance upon the birth is unable, by diligent inquiry, 
to obtain any item or items of information contemplated in section 14 of this act, it 
shall then be the duty of the local registrar to secure from the person so reporting, or 
from any other person having the required knowledge, such information as will enable 
h-im to prepare the certificate of birth herein contemplated, and it shall be the duty 
of the person reporting the birth, or who may be interrogated in relation thereto, to 
answer correctly and to the best of his knowledge all questions put to him by the local 
registrar which may be calculated to elicit any information needed to make a complete 
record of the birth as contemplated by said section 14, and it shall be the duty of the 
informant as to any statement made in accordance herewith to verify such statement 
by his signature, when requested so to do by the local registrar. 

Sec. 14. That the certificate of birth shall contain the following items, which are 
hereby declared necessary for the legal, social, and sanitary purposes subserved by 
registration records: ^ 

(1) Place of birth, including State, county, township or town, village, or city. 
If in a city, the ward, street, and house number; if in a hospital or other institution, 
the name of the same to be given, instead of the street and house number. 

(2) Full name of child. If the child dies without a name, before the certificate is 
filed, enter the words "Died unnamed." If the living child has not yet been named at 
the date of filing certificate of birth, the space for " Full name of child " is to be left 
blank, to be filled out subsequently by a supplemental report, as hereinafter provided. 

(3) Sex of child. 

(4) Y/hether a twin, triplet, or other plural birth. A separate certificate shall be 
required for each child in case of plural births. 

(5) For phu'al bii'ths, number of each child in order of birth. 

(6) Whether legitimate or ilegitimate.^ 

(7) Date of birth, including the year, month, and day. 

(8) Full name of father. 

(9) Eesidence of father. ' . 

(10) Color or race of father. 

(11) Age of father at last birthday, in years. 

(12) Birthplace of father; at least State or foreign country, if known. 

(13) Occupation of father. The occupation to be reported if engaged in any remun- 
erative employment, with the statement of («) trade, profession, or particular kind of 
work; (b) general nature of industry, business, or establishment in which employed 
(or employer). 

(14) Maiden name of mother. 

(15) Residence of mother. 

(16) Color or race of mother. 

(17) Age of mother at last birthday, in years. 

(18) Birthplace of mother; at least State or foreign country, if known. 

(19) Occupation of mother. The occupation to be reported if engaged in any 
remunerative employment, with the statement of (a) trade, profession, or particular 
kind of work; (b) general nature of industry, business, or establishment in which 
employed (or employer). 

1 The following items are those of the United States standard certificate of birth, approved by the Bureau 
of the Census. 

2 This qu:Etion may be omitted if desired, or provision may be made so that the identity of parents will 
not be disclosed. 



89 

(20) Number of children born to this mother, including present birth. 

(21) Number of children of this mother living. 

(22) The certification of attending phj^sician or midwife as to attendance at birth, 
including statement of year, month, day (as given in item 7), and hour of birth, and 
whether the child was born alive or stillborn. This certification shall be signed by 
the attending physician or midwife, with date of signature and address; if there is not 
physician or midwife in attendance, then by the father or mother of the child, house- 
holder, owner of the premises, or manager or superintendent of public or private 
institution where the birth occurred, or other competent person, whose duty it shall 
be to notify the local registrar of such bh'th, as required by section 13 of this act. 

(23) Exact date of filing in office of local registrar, attested by his official signature, 
and registered number of birth, as hereinafter provided. 

Sec. 15. That when any certificate of birth of a living child is presented without the 
statement of the given name, then the local registrar shall make out and deliver to the 
parents of the child a special blank for the supplemental report of the given name of 
the child, which shall be filled out as directed, and returned to the local registrar as 
soon as the child shall have been named. 

Sec. 16. That every physician, midwife, and undertaker shall, without delay, 
register his or her name, address, and occupation with the local registrar of the district 
in which he or she resides, or may hereafter establish a residence; and shall thereupon 
be supplied by the local registrar with a copy of this act, together with such rules and 
regulations as may be prepared by the State registrar relative to its enforcement. 
Within thirty days after the close of each calendar year each local registrar shall make 
a return to the State registrar of all physicians, midAvives, or xmdertakers who have 
been registered in his district during the whole or any part of the preceding calendar 
year: Provided, That no fee or other compensation shall be charged by local registrars 
to physicians, midwives, or undertakers for registering their names under this section 
or making returns thereof to the State registrar. ^ 

Sec. 17. That all superintendents or managers, or other persons m charge of hospitals, 
almshouses, lying-in, or other institutions, public or private, to which persons resort 
for treatment of diseases, confinement, or are committed by process of law, shall make 
a record of all the personal and statistical jjarticulars relative to the inmates in their 
institutions at the date of approval of this act, which are requned in the forms of the 
certificates jsrovided for by this act, as dnected by the State registrar; and thereafter 
such record shall be, by them, made for all future inmates at the time of their admit- 
tance. And in case of persons admitted or committed for treatment of disease, the 
physician in charge shall specify for entry in the record, the nature of the disease, and 
where, in his opinion, it was contracted. The personal particulars and information 
required by this section shall be obtained from the individual himself if it is practicable 
to do so; and when they can not be so obtained, they shall be obtained in as complete 
a manner as possible from relatives, friends, or other persons acquainted with the facts. 

Sec. 18. That the State registrar shall prepare, print, and supply to all registrars 
all blanks and forms Used in registering, recording, and preserving the returns, or in 
otherwise carrjdng out the purposes of this act; and shall prepare and issue such 
detailed instructions as may be required to procure the uniform observance of its pro- 
visions and the maintenance of a perfect system of registration; and no other blanks 
shall be used than those supplied by the State registrar. He shall carefully examine 
the certificates received monthly from the local registrars, and if any such are incom- 
plete or unsatisfactory he shall require such further information to be supplied as may 
be necessary to make the record complete and satisfactory. And all physicians, mid- 
wives, informants, or undertakers, and all other persons having knowledge of the facts, 
are hereby required to supply, upon a form provided by the State registrar or upon 

1 This section may be omitted if deemed .expedient and the duty of supplying instructions may be 
assumed by the State officer. 



90 

the original certificate, such, information as they may possess regarding any birth or 
death upon demand of tlie State registrar, in person, by mail, or through the local 
registrar : Provided, That no certificate of birth or death, after its acceptance for regis- 
tration by the local registrar, and no other record made in pursuance of this act, shall 
be altered or changed in any respect otherwise than by amendments properly dated, 
signed, and witnessed. The State registrar shall further arrange, bind, and perma- 
nently preserve the certificates in a systematic manner, and shall prepare and maintain 
a comprehensive and continuous card index of all births and deaths registered ; said 
index to be arranged alphabetically, in the case of deatlrs, by the names of decedents, 
and in the case of births, by the names of fathers and mothers. He shall inform all 
registrars what diseases are to be considered infectious, contagious, or communicable 
and dangerous to the public health, as decided by the State board of health, in order 
that when deaths occur from such diseases proper precautions may be taken to prevent 
their spread. 

If any cemetery company or association, or any church or historical society or asso- 
ciation, or any other company, society, or association, or any individual, is in posses- 
sion of any record of births or deaths which may be of value in establishing the geneal- 
ogy of any resident of this State, such company, society, association, or individual 
may file such record or a duly authenticated transcript thereof with the State regis- 
trar, ajid it shall be the duty of the State registrar to preserve such record or transcript 
and to make a record and index thereof in such form as to facilitate the finding of any 
information contained therein. Such record and index shall be open to inspection 
by the public, subject to such reasonable conditions as the State registrar may pre- 
scribe. If any person desires a transcript of any record filed in accordance herewith, 
the State registrar shall fnrnish the same upon application, together with a certificate 
that it is a true copy of such record, as filed in his office, and for his services in so 
furnishing such transcript and certificate he shall be entitled to a fee of (ten cents per 
folio) (fifty cents per hour or fraction of an hour necessarily consumed in making such 
transcript) and to a fee of twenty -five cents for the certificate, which fees shall be paid 
by the applicant. 

Sec. 19. That each local registrar shall supply blank forms of certificates to such 
persons as requii-e them. Each local registrar shall carefully examine each certificate 
of birth or death when presented for record in order to ascertain whether or not it has 
been made out in accordance with the provisions of this act and the instructions of 
the State registrar; and if any certificate of death is incomplete or unsatisfactory, it 
shall be his duty to call attention to the defects in the return, and to withhold the 
burial or removal permit tmtil such defects are corrected. All certificates, either of 
birth or of death, shall be written legibly, in durable black ink, and no certificate 
shall be held to be complete and correct that does not supply all of the items of infor- 
mation called for therein, or satisfactorily account for their omission. If the certificate 
of death is properly executed and complete, he shall then issue a burial or removal 
permit to the undertaker; pro-\dded, that in case the death occurred from some disease 
which is held by the State board of health to be infectious, contagious, or communi- 
cable and dangerous to the public health, no permit for the removal or other dis- 
position of the body shall be issued by the registrar, except under such conditions aa 
may be prescribed by the State board of health. If a certificate of bnth is incomplete, 
the local registrar shall inmiediately notify the informant and require him to supply 
the missing items of information if they can be obtained. He shall number consecu- 
tively the certificates of birth and death, in two separate series, beginning with number 
1 for the first bnth a/nd the first death in each calendar year, and sign hia name as 
registrar in attest of the date of filing in his office. He shall also make a complete and 
accurate copy of each birth and each death certificate registered by him in a record 
book supplied by the State registrar, to be preserved permanently in his office as the 
local record, in such manner as directed by the State registrar. And he shall, on the 



91 

tenth day of each month, transmit to the State registrar all original certificates regis- 
tered by him for the preceding month. And if no births or no deaths occurred in any 
month, he shall, on the tenth day of the following month, report that fact to the State 
registrar, on a card provided for such purpose. 

Sec. 20. That each local registrar shall be paid the sum of twenty-five cents for each 
birth certificate and each death certificate properly and completely made out and 
registered with him, and correctly recorded and promptly returned by him to the 
State registrar, as required by this act.^ And in case no births or no deaths were 
registered dm'ing any month, the local registrar shall be entitled to be paid the sum 
of twenty-five cents for each report to that effect, but only if such report be made 
promptly as requhed by this act. All amounts payable to a local registrar under the 
provisions of this section shall be paid by the treasm'er of the county in which the 
registration district is located, upon certification by the State registrar. And the 
State registrar shall annually certify to the treasurers of the several counties the num- 
ber of births and deaths properly registered, with the names of the local registrars and 
the amounts due each at the rates fixed herein.^ 

Sec. 21. That the State registrar shall, upon request, supply to any applicant a 
certified copy of the record of any birth or death registered under provisions of this 
act, for the making and certification of which he shall be entitled to a fee of fifty 
cents, to be paid by the applicant. And any such copy of the record of a bii'th or 
death, when properly certified by the State registrar, shall be prima facie evidence 
in all com'ts and places of the facts therein stated. For any search of the files and 
records when no certified copy is made, the State registrar shall be entitled to a fee 
of fifty cents for each hour or fractional part of an horn" of time of search, said fee to 
be paid by the applicant. And the State registrar shall keep a true and correct 
account of all fees by him received under these provisions, and tm-n the same over to 
the State treasurer: Provided, That the State registrar shall, upon request of any 
parent or guardian, supply, without fee, a certificate limited to a statement as to the 
date of birth of any child when the same shall be necessary for admission to school, 
or for the puj-pose of seeming employment: And provided further, That the United 
States Census Bureau may obtain, without expense to the State, transcripts, or certified 
copies of births and deaths without payment of the fees herein prescribed. 

Sec. 22. That any person, who for himself or as an officer, agent, or employee of any 
other person, or of any corporation or partnership (o) shall inter, cremate, or otherwise 
finally dispose of the dead body of a human being, or permit the same to be done, or 
shall remove said body from the primary registration district in which the death 
occurred or the body was found without the authority of a burial or removal permit 
issued by the local registrar of the district in which the death occurred or in which 
the body was found; or (h) shall refuse or fail to furnish con-ectly any infonnation in 
his possession, or shall furnish false information affecting any certificate or record, 
required by this act; or (c) shall willfully alter, otherwise than is provided by section 
18 of this act, or shall falsify any certificate of birth or death, or any record established 
by this act; or {d) being required by this act to fill out a certificate of birth or death 
and file the same with the local registrar, or deliver it, upon request, to any person 
charged with the duty of filling the same, shall fail, neglect, or refuse to perform such 
duty in the manner required by this act; or (e) being a local registrar, deputy registrar, 
or subregistrar, shall fail, neglect, or refuse to perform his duty as required by this 
act and by the instructions and direction of the State registrar thereunder, shall be 
deemed guilty of a misdemeanor, and upon conviction thereof shall for the first offense 
be fined not less than five dollars ($5) nor more than fifty dollars ($50), and for each 

1 A proviso may be inserted at this point relative to fees of city registrars wiio are already compensated 
by salary for their services. .See laws of Missouri, Ohio, and Pennsylvania. 

2 Provision may be made in this section for the payment of subregistrars and also, if desired, for the 
payment of physicians and midwives. See Kentucky law. 



92 

subsequent offense not less than ten dollars ($10) nor more than one hundred dollars 
($100), or be imprisoned in the county jail not more than sixty days, or be both fined 
and imprisoned in the discretion of the court. ^ 

Sec. 23. That each local registrar is hereby charged with the strict and thorough 
enforcement of the provisions of this act in his registration district, under the super- 
vision and direction of the State registrar. And he shall make an immediate report 
to the State registrar of any violation of this law coming to his knowledge, by observa- 
tion or upon complaint of any person or otherwise. 

The State registrar is hereby charged with the thorough and efficient execution 
of the provisions of this act in every part of the State, and is hereby granted euj^er- 
visory power over local registrars, deputy local registrars, and subregistrars to the 
end that all of its requirements shall be uniformly complied v>dth. The State regis- 
trar, either personally or by an accredited representative, shall have authority to 
investigate cases of irregularity or violation of law, and all registrars shall aid him, 
upon request, in such investigations. When he shall deem it necessary he shall 
report cases of violation of any of the provisions of this act to the prosecuting attorney 
of the county, with a statement of the facts and cii-cumstances; and when any such 
case is reported to him by the State registrar the prosecuting attorney shall forthwith 
initiate and promptly follow up the necessary court proceedings against the person 
or corporation responsible for the alleged violation of law. And upon request of 
the State registrar, the attorney general shall assist in the enforcement of the pro- 
visions of this act. 

Note. — Other sections should be added giving the date on which th? act is to <ro into effect, if not deter- 
mined by constitutional provisions of the Stitc; providing for the financial support of the law; and repeal- 
ing prior statutes inconsistent with the present act. 

It is desirable that the entire bill should be reviewed by competent legal authoritv for the purpose of 
discovering whether it can be made more consistent in any respect with the general form of legislation 
of the State in which the bill is to be introduced, without materia! change or injury to the effectiveness 
of registration. 



THE STANDARD BIRTH AND DEATH CERTIFICATES. 

The following are facsimile reproductions of the standard bnth and death certifi- 
cates. They have been reduced in size to meet the requirements of the printed 
page. The size of the birth certificate is 6^ by 7| inches, and of the death certificate 
7i by 8J inches. Copies can be obtained fi'om the Dhector of the Census upon 
request. 

1 Provision may be made whereby compliance witii this act shall constitute a condition of granting 
licenses to physicians, midwives, and embalmers. 



93 



United States Standard Certificate of Birth, 



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a S I I 



PLACE OF BIRTH 

County of _ 

Township of 

Viltagoof- 

City of - 



Be^artment at CofTTTprr? anh Bjabxif 



STANDARD CERTIFICATE OF BIRTH 



Registered No 

St.i Ward) 



FULL NAME OF 


CHILD - 














1 ir^cblld IB not yet named, m&ko 














Sex of 
Child 


Twin, Iripid, 
or other? 


Number In 

of birth 

event ol plu 


ore 


It., 


Lcgll- 
Imale? 




Date of 
birth 1 ,19 

( Month 1 ^ (Uay) (Venr) 


FULL 
NAME 


FATHER 








FULL 




MOTHER 


RESIDENCE 


RESIDENCE 


COLOR 


BIRTHDAY . 








COLOR 




AGE AT LAST 


{Y.-i,IB 








BIRTHPLACE 


BIRTHPLACE 


OCCUPATION 


OCCUPATION 




to this mother, including present birth 




... 


...1 Numborol children 


ofthi. 


n=therno„li.i„, 



I hereby certify that I atiended the birth of this child, v 
on the date above stated. 

(Signature) . 



CERTIFICATE OF ATTENDING PHYSICIAN OR MIDWIFE* 

ho was ----- at - 



• When titers teaa no alfendinff phyatdan \ 
or midioife, then the father, Hottseholdcr, S 
etc., should make thia return- A stitlbam > 
child in one that m^ithf-r- 7>r&atlt^a nor shovKS I 
other evidence of life after birth, ) 

Uiven name added from a supplemental Address- 
report ,19 



(Physician or Midwife) 



SUPPLEMENTAL REPORT OF BIRTH 



(STATE) 

(This retnrn Bboold preferably be taodo by Ihc ptreon 



Registered Number* 



Place ofbirfh* .„.,. A'o, 

-' (Begietration district) 



SEX OF CHILD" 



FULL* 

MAIDEt 
NAME 



Number • 
of birth 



(Pay) (Y«-ar) 



i out lUb form 



-St 



I HEREBr CERTIFY that the child described herein has 
been named: 



(Given nmnc. in full) (tunmmc) 
(Signature) - - - 

tPkyaklan ur midwifcj 



94 



United States Standard Certificate of Death. 





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IS 




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1 PLACE" OF DEATH 

County — -' — 

Township -■ 



Department of commercs 



STANDARD CERTIFICATE OF DEATH 
Stale of - - - -- -- 



8FIJLL NAME 



DMRL ano STriTSSTiCAL paRTICOLARS 



1 COLOR OR f 



'DATE OF BtF 



If LESS tha 



particular kind of work 

(b) General nature of industry, 
bua'nessi or establishment iti 



9 BIRTHPLACE 



'IFBCn7£ OF DEATH 



l OF DEATH 



, 191. 



14 THE ABOVE IS TRUE TO THE I 
(Informant) 

(Address)..- 



Filed . 191 



L7 i HEREBY CERTIFY, That i attended deceased from 
_-, 191 — , to , \9\ — , 

that Mast saw h alive on , i91..-, 

and that death occurredi on the date stated above, at —m, 

The CAUSE OF DEATH* was as follows: 



_ (Duratlor)., yrj. „_ mo:; dj. 

Contributory - - «- 

„ (Duration) _ yrs. mas (ffc 

(Slsr.ed)- .- — - .H. D. 

......191 — . (AddresO- 






(1) 1 



1 C^) V 






'■SLEHOTH OF RESIDENCE (FOR HOSPITALS, |" 
OR necE?i7 Resioekts) 

At placo In tha 



_d3. State yn. 



Whore was disease contracted, 
Ifnotatplaceofdeatfi? 



19 PLACE OF BURIAL OR REMOVAL 



DATE OF BURIAL 



OUNOERTAKER 



ADDITIONAL COPIES 

OF THIS PUBLICATION MAY BE PROCURED FROM 

THE SUPERINTENDENT OF DOCUMENTS 

GOVERNMENT PRINTING OFFICE 

WASHINGTON, D. C. 

AT 

10 CENTS PER COPY 



